Print Sample Chapter - Elsevier Australia

WONG’S Nursing Care of Infants and Children

•••••••••

Australian adaptation edited by:

Lisa Speedie, RN Div 1, BN, Grad Dip Women’s Health, MNSSenior Fellow, Higher Education Academy (United Kingdom)Lecturer, School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt UniversityHigher Education Research and Development Society of Australasia memberAustralian College of Nursing member

Andrea Middleton, RN, BN (Hons), MCN (Paediatrics)Clinical Nurse Educator (Paediatrics), Centre for Education and Research, Royal Hobart HospitalTasmanian Health Service—SouthLecturer, School of Nursing, College of Health and Medicine, University of Tasmania

US editors:

Marilyn J. Hockenberry, PhD, RN, PPCPNP-BC, FAANProfessor of PediatricsBaylor College of MedicineDirector, Global HOPE NursingTexas Children’s HospitalHouston, TexasBessie Baker Professor Emerita of NursingChair, Duke Institutional Review BoardDuke UniversityDurham, North Carolina

David Wilson, MS, RN, C(INC), (deceased)StaffChildren’s Hospital at Saint FrancisTulsa, Oklahoma

Cheryl C. Rodgers, PhD, RN, CPNP, CPON (deceased)Associate ProfessorChair, Duke Institutional Review BoardDuke University School of NursingDurham, North Carolina

AUSTRALIA AND NEW ZEALAND EDITION—FOR STUDENTS

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DedicationTo April and Tiffany

‘The future belongs to those who believe in the beauty of their dreams.’ (Eleanor Roosevelt)

To Benjamin, Samuel and Jacob

‘The more that you read, the more things you will know. The more that you learn, the more places you’ll go.’ (Dr Seuss)

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AU S T R A L I A N A N D N E W Z E A L A N D C O N T R I B U T O R S

Lauren Kendrick, RN, BN, MN, GradCert (Neonatal Intensive Care)Senior Academic Staff Member and

Neonatal Paper CoordinatorSchool of NursingAuckland University of TechnologyAucklandNeonatal Intensive Care UnitStarship Child HealthAuckland District Health BoardNew Zealand

Elyce Kenny, RN, BN, GradCert (Nurs Ed), GradDip (Paed, Child and Yth Hlth Nursing)LecturerAdelaide Nursing SchoolThe University of AdelaideAdelaide, South AustraliaAustralia

Christine Taylor, RN, BAppSc (Adv Nsg), BSc (Hons), MHScEd, PhD, MACNSenior LecturerSchool of Nursing and MidwiferyWestern Sydney UniversityParramatta, New South WalesAustralia

Lynne Staff, RN, RM, MMid (Hons)Lecturer in Nursing and MidwiferySchool of NursingUniversity of TasmaniaLaunceston, HobartAustralia

Amy Vaccaro, RN, RM, BN, MMid, GradCert (Acute Care)Clinical Support Nurse/MidwifeAlbury–Wodonga Health and Sessional

LecturerSchool of Nursing, Paramedicine and

Healthcare ScienceCharles Sturt UniversityAlbury, New South WalesAustralia

Emma Collins, RN, BEd, MN, DipTchng, PGCert (Higher Ed), FHEAProfessional Practice FellowWomen’s and Children’s HealthUniversity of OtagoDunedinNew Zealand

Tameeka Mulquiney, RN, RM, MMid (Dist)LecturerSchool of Nursing, Paramedicine and

Healthcare ScienceCharles Sturt UniversityAlbury, New South WalesAustralia

Deb Surman, RN, DipNsg, BN, GradCert (Emerg Nsg), MNSenior Academic Staff MemberSchool of NursingWaikato Institute of Technology (Wintec)HamiltonNew Zealand

Patience Moyo, RN, M (AdNursPrac), GradCert (LTHE), GradCert (Acute Care Nurs), MACNLecturer in NursingSchool of Nursing, Paramedicine and

Healthcare ScienceCharles Sturt UniversityDubbo, New South WalesAustralia

Kylie Smith, RN, DipHlthSci (Nursing)eClinicianClinical eHealth Project teamHealth ICTDubbo, New South WalesAustralia

Felicity Radford, RN, BNursPaediatric Registered NursePaediatric UnitDubbo Health ServiceDubbo, New South WalesAustralia

Julia Laing, RCompN, MHScClinical Nurse SpecialistWaikids—Waikato Child and Youth HealthWaikato District Health BoardWaikatoNew Zealand

Jane Mateer, NSC, RN, Cert Emergency, GD Nurse Specialisation (NP), MPH, FCENAClinical Nurse EducatorMonash Children’s HospitalMelbourne, New South WalesAustralia

Maryanne Podham, RN, BHlthSci, MN (Clinical Education), MACN,Lecturer in NursingSchool of Nursing, Paramedicine and

Healthcare ScienceCharles Sturt UniversityDubbo, New South WalesAustralia

Ibi Patane, RN, BN, GCPCYHN, GradDip (EBP), MNsg, CCN, FHEAClinical LecturerSchool of NursingQueensland University of TechnologyBrisbane, QueenslandAustralia

Sarah Dechert, RN, BN, PostGradCert (Neonatal Intensive Care)Associate Nurse Unit ManagerSpecial Care NurseryAlbury Wodonga HealthWodonga, VictoriaAustralia

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C O N T R I B U T O R S T O U S E D I T I O N

Caroline E. Anderson, RN, MSN, CPHONClinical Practice and Advanced Education

SpecialistCook Children’s Medical CenterFort Worth, Texas

Annette L. Baker, RN, BSN, MSN, CPNPPediatric Nurse PractitionerDepartment of CardiologyBoston Children’s HospitalBoston, Massachusetts

Rose Ann Urdiales Baker, PhD, PMHCNS, RNAssociate InstructorSchool of NursingCollege of Health ProfessionsUniversity of AkronAkron, Ohio

Raymond C. Barfi eld, MD, PhDProfessor of Pediatrics and Christian

Philosophy; Director, Medical Humanities

Pediatrics, and Trent Center for Bioethics, Humanities, and History of Medicine

Duke UniversityDurham, North Carolina

Amy Barry, MSN, RN, PNP-BCPediatric Nurse PractitionerChildren’s Healthcare of AtlantaAtlanta, Georgia

Heather Bastardi, RN, cPNP, CCTCPediatric Nurse PractitionerAdvanced Cardiac TherapiesBoston Children’s HospitalBoston, Massachusetts

Debra Brandon, PhD, RN, CNS, FAANAssociate ProfessorSchool of NursingDuke UniversityAssociate ProfessorDepartment of Pediatrics, School of

MedicineDuke UniversityNeonatal CNSDuke Intensive Care NurseryDurham, North Carolina

Rosalind Bryant, PhD, RN-CS, PNPClinical InstructorBaylor College of MedicineHouston, Texas

Cynthia J. Camille, MSN, RN, CPNP, FNP-BCPediatric Nurse PractitionerPediatric UrologyDuke University Health SystemDurham, North Carolina

Brigit M. Carter, PhD, RN, CCRNDirectorAccelerated BSN ProgramDuke University School of NursingDurham, North Carolina

Lisa M. Cleveland, PhD, RN, PNP-BC, IBCLC, NTMNCAssistant ProfessorSchool of NursingUT Health San AntonioSan Antonio, Texas

Patricia Conlon, MS, APRN, CNS, CNPPediatric Clinical Nurse SpecialistAssistant Professor of NursingMayo Clinic Children’s CenterRochester, Minnesota

Erin Connelly, APRN, CPNP, CPONDevelopmental Therapeutics Nurse

PractitionerDepartment of HematologyChildren’s Healthcare of AtlantaClinical Manager of Advance PracticeDepartment of OncologyAfl ac Cancer and Blood Disorders CenterAtlanta, Georgia

Anne Derouin, DNP, APRN, CPNP, FAANPAssociate Professor, Faculty Lead, MSN/

PNP-PC and Pediatric Behavioral Mental Health Specialty

School of NursingDuke UniversityDurham, North Carolina

Sharron L. Docherty, PhD, PNP-BC, FAANAssociate ProfessorDepartment of PediatricsDuke UniversityDurham, North Carolina

Angela Drummond, MS, APRN, CPNPPediatric Nurse Practitioner–OrthopedicsGillette Children’s Specialty HealthcareSt Paul, Minnesota

Elizabeth A. Duffy, DNP, RN, CPNPClinical Assistant ProfessorHealth Behavior and Biological SciencesThe University of Michigan School of NursingAnn Arbor, Michigan

Kimberley Fisher, PhD, FNP-BCResearch DirectorNeonatal Perinatal Research UnitDivision of NeonatologyDuke UniversityDurham, North Carolina

Jan M. Foote, DNP, CPNP, ARNP, FAANPPediatric Nurse PractitionerBlank Children’s HospitalDes Moines, IowaAdjunct Clinical Associate ProfessorUniversity of Iowa College of NursingIowa City, Iowa

Quinn Franklin, MS, CCLSAssistant DirectorPsychosocial DivisionCancer and Hematology CentersTexas Children’s HospitalHouston, Texas

Ruth Anne Herring, MSN, RN, CPNP-AC/PC, CPHONPediatric Nurse PractitionerCenter for Cancer and Blood DisordersChildren’s HealthDallas, Texas

Mystii Kidd, MSN, RN, CPNPPediatric Nurse PractitionerTLC Pediatrics, PAAllen, Texas

Teri A. Huddleston Lavenbarg, MSN, APRN, PPCNP-BC, FNP-BC, CDENurse PractitionerMedical CenterUniversity of KansasKansas City, Kansas

Shirley D. Martin, PhD, RN, CPNOutpatient SurgeryCook Children’s Medical CenterFort Worth, Texas

Maggie Maxtin, RN, BSN, CPNHematology/Oncology RNCook Children’s Medical CenterFort Worth, Texas

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x CONTRIBUTORS TO US EDITION

Patricia Barry McElfresh, MN, RN, PNPClinical Program Manager—Advanced

Practice ProvidersHematology Oncology-Bone Marrow

FailureAfl ac Cancer & Blood Disorders CenterAtlanta, Georgia

Tara Merck, MSN, APRN, CPNPDirector of Advanced Practice ProvidersChildren’s Specialty GroupMedical College of WisconsinMilwaukee, Wisconsin

Mary A. Mondozzi, MSN, BSN, WCCBurn Center Education/Outreach

CoordinatorThe Paul and Carol David Foundation Burn

InstituteAkron Children’s HospitalAkron, Ohio

Rebecca A. Monroe, MSN, RN, CPNPPediatric Nurse PractitionerCollin County PediatricsFrisco, Texas

Kim Mooney-Doyle, PhD, CPNP-AC, RNAssistant ProfessorSchool of NursingUniversity of MarylandBaltimore, Maryland

Patricia O’Brien, CPNP-ACNurse PractitionerCardiologyBoston Children’s HospitalBoston, Massachusetts

Sue Park, APN, CPNP-PCPediatric Nurse PractitionerPediatric AnesthesiaAnn and Robert H. Lurie Children’s

Hospital of ChicagoChicago, Illinois

Katherine Soss Prihoda, DNP, RN, PPCNP-BCAssistant ProfessorSchool of NursingRutgers University, CamdenCamden, New Jersey

Cynthia A. Prows, MSN, APRN, FAANClinical Nurse SpecialistHuman Genetics and Patient ServicesCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

Patricia A. Ring, MSN, RN, CPNPPediatric NephrologyChildren’s Hospital of WisconsinMilwaukee, Wisconsin

Kathleen S. Ruccione, PhD, RN, MPH, CPON, FAANAssociate Professor and ChairDepartment of Doctoral ProgramsAzusa Pacifi c UniversityAzusa, California

Margaret L. Schroeder, MSN, RN, PPCNP-BCPediatric Nurse PractitionerCardiovascular SurgeryBoston Children’s HospitalBoston, Massachusetts

Maureen Sheehan, CPNPChild Neurology, Epilepsy, and Ketogenic

Diet Nurse PractitionerChild Neurology and Advanced PracticeStanford Children’s HealthPalo Alto, California

Katherine Smalling, RN, BSN, CPONNurse Case ManagerChildren’s Medical Center DallasCenter for Cancer and Blood DisordersDallas, Texas

Anne Feierabend Stanton, APRN, PCNS, BCPediatric Clinical Nurse SpecialistUniversity of Kansas Medical CenterKansas City, Kansas

Alexandra Kathleen Superdock, MDPediatric ResidentUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

Barbara J. Wheeler, RN, MN, IBCLCNeonatal Clinical Nurse SpecialistSt Boniface General HospitalWinnipeg, Canada

Kristina D. Wilson, PhD, CCC-SLPSenior Speech Pathologist and Clinical

ResearchDivision of Speech, Language, and LearningTexas Children’s HospitalHouston, Texas

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Alexandra KAlexandraPediatric PediatricUniveUni

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AU S T R A L I A N A N D N E W Z E A L A N D R E V I E W E R S

Kelly Grant, RN, BN, MCN (Paediatrics)Clinical Nurse ConsultantChildren’s and Adolescent WardRoyal Hobart HospitalHobart, TasmaniaAustralia

Gracie Patten, RN, BN (ClinHons), GradCertN (Paediatrics)Children’s and Adolescent WardRoyal Hobart HospitalHobart, TasmaniaAustralia

Leah Campbell, RN, BN, GradCertN (Paediatrics)Children’s and Adolescent WardRoyal Hobart HospitalHobart, TasmaniaAustralia

Grace Shallard, MPhil (Nursing)Nurse Specialist, Child ProtectionTe Puaruruhau, Starship Children’s HospitalAucklandNew Zealand

Lola Bishop, RN, BNsg, CCHNS (CAFHN), Cert IV TAELLN, M (Professional Education &Training)LecturerFlinders UniversityAdelaide, South AustraliaAustralia

Deaane Terlich, RN, RM, EMAlbury Wodonga HealthWodonga, VictoriaAustralia

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xiii

P R E FA C E

The fi rst edition of Wong’s Nursing Care of Infants and Children adap-tation for Australia and New Zealand was a huge undertaking espe-cially when the decision was made to edit two versions, Student and Professional. As co-editors we began the challenge of sourcing con-tributors from both Australia and New Zealand and, due to the two versions, sourced both academics and clinical experts.

In a rapidly changing environment, supporting the educational needs of nurses working with infants, children and young people and their families is essential. At a time where nurse recruitment and reten-tion is at the forefront of healthcare in both Australia and New Zea-land, nurses need to be supported to provide safe and fulfi lling care across many clinical contexts, such as tertiary centres, paediatric units within adult-focused hospitals, emergency departments, theatres, rural centres and outpatient clinics, just to name a few. We hope that Wong’s Nursing Care of Infants and Children fi nds a place in supporting both students new to paediatric nursing and nurses who have found their niche in caring for infants, children, young people and their families and want to enhance their expertise in the care they provide.

We would like to take a moment to refl ect on the legacy of this textbook. The fi rst edition of Whaley and Wong’s Nursing Care of Infants and Children, published by Elsevier in 1979, was the fi rst of its kind to integrate important principles from the biological, physical and behavioural sciences into a paediatric nursing textbook. With the fi rst United States (US) edition, the principles and concepts of nursing practice were conceptualised to give both nursing students and experi-enced nurses an opportunity to expand and refi ne nursing care; this proves true with the 11th US edition. This, the fi rst Australian and New Zealand (ANZ) edition, has divided the US text, providing the student with a more streamlined text suited to their beginner needs. The pro-fessional text contains more in-depth content and appropriate research cues for nurses practising paediatric nursing. Neither text has come without its challenges for both ourselves as editors and for the con-tributors. Asking such passionate and knowledgeable contributors to split the content was diffi cult.

The fi rst ANZ edition clearly refl ects 21st-century changes in pae-diatric nursing and demonstrates how scientifi c evidence has had a signifi cant impact on the specialty in the ANZ environment. It contin-ues to be about providing best practice care to children their families, and it emphasises the philosophy of family-centred care. This book has retained the theme that Donna Wong so passionately advocated: pro-viding care that minimises the psychological and physical stress that health promotion and illness can infl ict. The fi rst edition’s preface stated, ‘This book truly embodies the concept of [family-centred] care.’ We are proud to note that with this new edition, this foundation re-mains true. Features such as Family-centred Care, Community Focus and Nursing Care Considerations boxes bring these philosophies to life throughout the text. We believe strongly that children and families need consistent caregivers. Establishing therapeutic relationships with the child and family is explored as the essential foundation for provid-ing quality nursing care.

This fi rst ANZ edition has been revised to keep pace with new in-novations in paediatric nursing care, particularly in Australia and New Zealand. We feel a unique accountability and responsibility to continue to strive to provide students and professionals with the latest informa-tion they need to become competent critical thinkers and to attain the sensitivity necessary to become caring paediatric nurses. As editors for the fi rst ANZ Wong textbooks, we have developed an expert panel of more than 20 nurses and multidisciplinary specialists who assisted in

reviewing, revising, rewriting and authoring portions of the text on areas undergoing rapid and complex change, such as immunisations, genetics, high-risk newborn care, adolescent health issues, numerous diseases and care specifi c to Aboriginal and Torres Strait Islander and Māori children and families. We have carefully preserved aspects of the book that have met with such universal acceptance—its state-of-the-art evidence-based information; strong, integrated focus on the family and community; logical and user-friendly organisation; and easy read-ing style. We have placed additional emphasis on research with concise reviews of important evidence in Research Focus boxes within the Professional edition. With this fi rst ANZ edition we emphasised the importance of care evaluation and have added Nursing Care Consid-eration boxes throughout the book to demonstrate how quality of care can be assessed among the paediatric population. This feature allows students and professionals to review new evidence and quality indica-tors on important topics in a concise way.

Pathophysiology review fi gures throughout the text provide a con-cise evaluation of major healthcare diseases in children. With an un-derstanding of the pathophysiological process, the nurse is better pre-pared to develop evidence-based nursing interventions for patient care. In addition, more than 130 fi gures are colour enhanced to focus on the importance on visual learning. This provides the visual learner with a tangible connection to the content of the text for application to clinical practice.

Within the Student edition we have tried to meet the increasing demands of faculty and students to teach and to learn in an environ-ment characterised by rapid change, enormous amounts of informa-tion, fewer traditional clinical facilities and less time to teach. To help students quickly locate essential information, most of the features used in the US edition have been retained. Within the Professional edition we continue to use Evidence-Based Practice boxes incorporating the PICOT approach and GRADE evidence quality assessment criteria. Most importantly, this text continues to encourage professionals to think critically.

These two texts serve as reference manuals for the practising stu-dent nurse and professional. The latest recommendations have been included from authoritative organisations such as the Royal Children’s Hospital Melbourne, Sydney Children’s Hospital, Australian Institute of Health and Welfare, Ministry of Health New Zealand, Wellington Children’s Hospital and Starship Children’s Hospital, Auckland. To expand the universe of available information, websites have been in-cluded for many of organisations and other educational resources used and referenced throughout the two texts.

ORGANISATION OF THE BOOKThe same general approach to the presentation of content has been preserved from previous US editions, although much content has been added, condensed and rearranged within this framework to improve fl ow, minimise duplication, emphasise healthcare trends (such as home and community care) and ensure the relevance to Australia and New Zealand. The two books continue to be divided into two broad parts. The fi rst part of the book, sometimes called the ‘age and stage’ approach, considers infancy, childhood and adolescence from a devel-opmental context. It emphasises the importance of the nurse’s role in health promotion and maintenance and in considering the family as the focus of care. From a developmental perspective, the care of common health problems is presented, giving readers a sense of what

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xiv PREFACE

normal problems can be expected in otherwise healthy children and demonstrating when during childhood these problems are most likely to occur. The second part of the book presents the more serious health problems not specifi c to any particular age group but that frequently require hospitalisation or major medical and nursing interventions. Both books also take into consideration cultural needs and a rural and remote aspect addressing the needs of ANZ children and families.

Unit I (Chapters 1 to 3) provides an overview of the multitude of infl uences on a child who is developing as a member of a family unit and maturing within a culture, community and society. Chapter 1 includes a discussion of morbidity and mortality in infancy and child-hood and examines child healthcare from a historical perspective. Because unintentional injury is one of the leading causes of death in children, an overview of this topic is included. The chapter presents the nursing process with an emphasis on nursing diagnosis and outcomes and the Professional edition focuses on the importance of developing critical thinking skills. The critical components of evidence-based practice provide the template for exploring the latest paediatric nurs-ing research and practice guidelines throughout the Professional edition. Discussion of nursing care considerations and their impor-tance in evaluating the quality of nursing care has been added in several sections of the Student edition.

Chapter 2 in both books provides the opportunity to expand the discussion of social, cultural, religious, rural/regional and family infl uences on child development and health promotion, including socioeconomic factors, customs and health beliefs and practices. The content clearly describes the role of the nurse, with such information as guidelines for culturally sensitive interactions and nursing con-sideration discussions.

Unit II (Chapters 4 to 6) is concerned with the principles of critical nursing assessment by keeping pace with the newest evaluation strate-gies in nursing. Chapter 4 contains guidelines for communicating with children, adolescents and their families; telephone triage; and a detailed description of a health assessment, including an extensive discussion of family assessment and nutritional assessment. This chapter provides a comprehensive approach to physical examination and developmental assessment, using the latest literature.

In this edition, an important chapter with new contributors is devoted to critical assessment and management of pain in children. Although the literature on pain assessment and management in child-ren has grown considerably, this knowledge has not been widely applied in practice. Chapter 5 addresses this concern by presenting detailed pain assessment and management strategies, including dis-cussion of common pain states in children. Chapter 6 was a newly developed chapter for the 11th US edition focusing on the various infectious diseases encountered in childhood, and has been adapted to include ANZ infectious requirements. In addition, it details hospital-acquired infections, childhood communicable diseases and childhood immunisations within both books.

Unit III (Chapters 7 to 9) in both books stresses the importance of the neonatal period, the time of greatest risk to a child’s survival, and discusses several health concerns encountered in the vulnerable fi rst month of life. Chapter 7 has been updated and revised to include the latest information on the benefi ts of breastfeeding. Nursing consider-ation sections have been revised to include the latest evidence-based recommendations for pain management in newborns. Newborn screening guidelines have also been extensively updated. Chapter 8 has also been revised and updated. The latest guidelines for the man-agement of hyperbilirubinaemia in late-preterm and term newborns and for follow-up and management of hyperbilirubinaemia in the breastfeeding pair are included in this edition. Updated management protocols for neonatal hypoglycaemia are also included. Nursing

considerations of the newborn remains an important concept in these chapters. Evidence-based practice and critical thinking exercises have also been updated in the Professional book. Chapter 9 contains infor-mation regarding maternal conditions that may adversely affect the fetus and newborn, including maternal viruses, maternal diabetes, fetal alcohol and tobacco exposure, and neonatal drug exposure.

Units IV through VII (Chapters 10 to 18) in both books present the major developmental stages in childhood, expanded to provide a broader concept of the stages and the health problems most often associated with each age group. Special emphasis is placed on the preventive aspects of care. The health promotion chapters follow a standard approach that is used consistently for each age group.

The chapters on health problems primarily refl ect typical and age-related concerns. The information on many disorders has been revised to refl ect recent changes, particularly within Australia and New Zealand. Examples include the latest information on food sensitivity, attention-defi cit/hyperactivity disorder, contraception, teenage pregnancy, sub-stance abuse, self-harm and eating disorders such as anorexia nervosa and childhood obesity. The section on sudden infant death syndrome (SIDS) has been extensively updated to include the latest ANZ consider-ations for recognised SIDS protective and risk factors. A common theme in these chapters is the recognition of the impact of accidental childhood injury on childhood morbidity and mortality and efforts for prevention of such injuries.

Childhood obesity information is now located in the school-age child chapter to emphasise the need for earlier assessment and inter-vention of this health problem. Sections on male and female reproduc-tive health conditions, sexual orientation and gender identity and support have been revised and updated.

Unit VIII (Chapters 19 and 20) in both books deals with children who have the same developmental needs as growing children but who, because of congenital or acquired physical, cognitive or sensory impairment, require alternative interventions to facilitate develop-ment. Chapter 19 combines discussions of chronic illness, disability and end-of-life care for the child and family. It refl ects the latest trends in the care of families and children with chronic illness or disability, such as home care, normalising children’s lives, focusing on develop-mental needs, enabling and empowering families and providing early intervention. The content in Chapter 20 on cognitive, sensory and communication impairment includes the latest information on cognitive impairment and learning disorders.

Unit IX (Chapters 21 and 22) is concerned with the impact of hospitalisation on the child and the family and presents a comprehen-sive overview of the stressors imposed by hospitalisation and nursing interventions available to prevent or eliminate these stressors. Chapter 21 discusses the care of the hospitalised child and family with consid-eration for increasing care in ambulatory centres. Chapter 22 explores safe implementation of procedures in children, including emphasis on the use of therapeutic holding. The Professional edition also includes numerous boxes that are designed to provide rationales for the inter-ventions discussed in this edition. Recommendations for practice are based on the evidence and are concisely presented in boxes throughout the chapter.

Units X through XIV (Chapters 23 to 34) in both books consider serious health problems of infants and children primarily from a biological system orientation, which has the practical organisational value of permitting healthcare problems and nursing considerations to relate to specifi c pathophysiological disturbances. Important addi-tions and revisions include discussion of blood disorders, acute respiratory distress syndrome and the latest classifi cation for asthma, seizures, chemotherapy, diabetes mellitus and burns. Examples of the updates and revisions for these units include Chapter 27 on the child

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xvPREFACE

well. However, it is not sufficient to prepare students to care pri-marily for sick children. First, health is more than the absence of disease. Being healthy is being whole in mind, body and spirit; therefore, the majority of the first half of the book is devoted to discussions that promote physical, psychosocial, mental and spiri-tual wellness. Much emphasis is placed on anticipatory guidance of parents to prevent injury or illness in the child. Second, more than ever, healthcare is prevention focused. Competent nursing care flows from this knowledge and is enhanced by an awareness of childhood development, family dynamics and communication skills. The books are enhanced further with Critical Thinking Case Study boxes within the Student edition and Research Focus boxes in the Professional edition.

Nursing CareAlthough both books incorporate information from numerous disci-plines (e.g. medicine, pathophysiology, pharmacology, nutrition, psy-chology, sociology), its primary purpose is to provide information on the nursing care of children and families. Discussions of disorders conclude with a section on Nursing Care Management. Although many aspects of the nursing care of children and families have changed signifi cantly over the last few decades, the focus must con-tinue to be on the quality of care. For the quality of care to be main-tained, paediatric nurses must be proactive in staying informed about the strength of evidence that supports specifi c nursing practices. The Nursing Care Considerations sections are designed to provide the latest evidence for the implementation of evidence-based nursing practice.

Critical Role of Research and Evidence-based PracticeThis fi rst ANZ edition is the product of an extensive review of the literature published within the 11th US edition and from ANZ con-tributors. In addition, Research Focus boxes provide the professional with a concise discussion of the latest research on a given topic. So that information is accurate and current, most citations are less than 5 years old, and almost every chapter has entries within 1 year of publication. Examples of current cutting-edge information include recommendations from the appropriate ANZ paediatric providers and government sites.

• • •

Just as children and their families bring with them a value system and unique background that affect their role within the healthcare system, so too must each nurse bring to each child and family an individual set of characteristics and values that will affect their relationship. Although we have attempted to present a total picture of the child in each age group, both in wellness and in illness, no one child, family or nurse will be found in these books. We hope that each page, chapter and unit builds a foundation on which the nurse can begin to construct an ideal of comprehensive, atraumatic and individualised nursing care for infants, children, adolescents and their families.

with cardiovascular dysfunction, which has major revisions to the latest guidelines for assessment and management of the most common heart disorders in children, and Chapter 34, which includes updates on Guillain-Barré syndrome, cerebral palsy and respiratory management of neuromuscular conditions such as spinal muscular atrophy and muscular dystrophy.

UNIFYING PRINCIPLESSeveral unifying principles have guided the organisational structure of the US book since its inception and we have continued this in the ANZ 1st edition. These principles continue to strengthen the book with each revision to maintain a consistent approach throughout each chapter and we felt it was important to maintain this approach in the ANZ edition.

The Family as the Unit of CareThe child is an essential member of the family unit. Nursing care is most effective when it is delivered with the belief that the family is the patient. This belief permeates the book. The family is seen as a myriad of struc-tures; each has the potential to provide a caring, supportive environment in which the child can grow, mature and maximise his or her human potential. In addition to family-centred care being integrated into every chapter, an entire chapter is devoted to understanding the family as the core focus in children’s lives. Another chapter discusses the social, cul-tural and religious infl uences on family beliefs. Separate sections in yet another chapter deal in depth with family communication and family assessment. The impact of illness, hospitalisation and the death of a child are covered extensively in three additional chapters.

An Integrated Approach to DevelopmentChildren are not small adults but are special individuals with unique minds, bodies and needs. No book on paediatric nursing is complete without extensive coverage of communication, nutrition, play, safety, dental care, sexuality, sleep, self-esteem and, of course, parenting. Nurses promote the healthy expression of development and need to understand how this is observed in children at different ages and stages. Effective parenting depends on the parents’ knowledge of devel-opment, and it is often the nurse’s responsibility to provide parents with a developmental awareness of their children’s needs. For these reasons, coverage of the many dimensions of childhood is integrated within each developmental-stage chapter, rather than being presented in a separate chapter. Safety concerns, for instance, are very different for a toddler to those of an adolescent. Sleep needs change with age, as do nutritional needs. As a result, the units on each stage of child-hood contain complete information on all these subjects as they relate to the specifi c age. Using the integrated approach, students and profes-sionals gain an appreciation for the unique characteristics and needs of children at every age and stage of development.

Focus on Wellness and Illness: Child, Family and CommunityIn a paediatric nursing text, a focus on illness is expected. Children become ill, and nurses typically are involved in helping children get

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S P E C I A L F E AT U R E S

Much effort has been directed towards making this book easy to teach from and, more importantly, easy to learn from. In this edition, the following features have been included to benefi t educators, students and practitioners/professionals.

APPLYING EVIDENCE TO PRACTICE

Applying Evidence to Practice boxes are new specialty boxes through-out the Professional edition outlining up-to-date procedures to show best practice and focus on applying evidence.

NURSING CARE CONSIDERATIONS

Nursing Care Considerations boxes highlight important factors to enhance critical thinking. These could be to identify signs or triggers for deterioration and the importance of providing competent care without creating undue physical and psychological distress.

L E A R N I N G O U T C O M E S

Learning Outcomes have been added to the beginning of each chapter to focus the attention of students and professionals on the unique principles found in each chapter, as well as to aid students and profes-sionals in using concept-based curricula, system-focused curricula or a hybrid approach.

CRITICAL THINKING CASE STUDY

Critical Thinking Case Study boxes have been revised in this Student edition to describe brief scenarios of the child-family-nurse interac-tion that depict real-life clinical situations. From the synthesis of the topical content and a critical analysis of possible options, the reader builds on their knowledge of intervention and learns to make clinical judgments.

CULTURAL CONSIDERATIONS

Cultural Considerations boxes integrate concepts of culturally sensitive care throughout both texts. Their emphasis is on the clinical application of the information.

DRUG ALERT

Drug Alert boxes highlight critical drug safety concerns for better therapeutic management.

FAMILY-CENTRED CARE

Family-centred Care boxes present issues of special signifi cance to families who have a child with a particular disorder. This feature is another method of highlighting the needs or concerns of families that should be addressed when family-centred care is provided.

?

NURSING CARE GUIDELINES

Nursing Care Guidelines boxes summarise important nursing inter-ventions for a variety of situations and conditions.

NURSING CARE PLAN

Nursing Care Plan boxes include expected patient outcomes and ratio-nales for the included nursing interventions that may not be immedi-ately evident to the student. The care plans include a case study that represents a ‘real’ patient and family to demonstrate the principles of nursing care plans and how they are used to organise care.

QUALITY PATIENT OUTCOMES

Quality Patient Outcomes boxes are added throughout the text to pro-vide a framework for measuring nursing care performance. Nursing-sensitive outcome measures are integrated into the outcome indicators used throughout the book.

RESEARCH FOCUS

Research Focus boxes review new evidence on important topics in a concise way.

TRANSLATING EVIDENCE INTO PRACTICE

Translating Evidence into Practice boxes have been completely revised in this edition to focus the reader’s attention on application of both research and critical thought processes to support and guide the out-comes of nursing care and to provide measurable outcomes that nurses can use to validate their unique role in the healthcare system.

Numerous pedagogic devices that enhance student learning have been retained from previous editions.• More than 100 COLOUR PHOTOGRAPHS are included in this

edition to refl ect the latest in nursing care. Anatomical drawings are easy to follow, with appropriate use of colour to illustrate impor-tant aspects, such as saturated and desaturated blood. New fi gures refl ecting a PATHOPHYSIOLOGY REVIEW of various disorders have been added throughout the book. For example, the full-colour heart illustrations in Chapter 27 clearly depict congenital cardiac defects and associated haemodynamic changes.

• A functional and attractive FULL-COLOUR DESIGN visually en-hances the organisation of each chapter, as well as the special features.

• An INDEX, detailed and cross-referenced, allows readers to quickly access discussions.

• KEY TERMS are highlighted throughout each chapter to reinforce student learning.

• BLOOD PRESSURE LEVELS on the inside back cover provide information nurses refer to often.

• Hundreds of TABLES and BOXES highlight key concepts and nursing interventions.

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xix

A C K N O W L E D G M E N T S

This fi rst edition of the Australia and New Zealand Wong’s Nursing Care of Infants and Children brings with it not only two new co-editors but numerous new contributors from both countries. We have continued the excellence in nursing education and knowledge by seeking contributors from diverse backgrounds, bringing a wealth of expertise to the ANZ edition and to paediatric education and nursing. We are grateful for their time and contribution to this new project and to the commitment and many hours that they have provided during a very diffi cult time due to COVID-19. We are thankful and appreciative of the many hours reviewers have also given to provide constructive feedback to assist with this challenging project. The books would never have been completed without the enormous task undertaken by these professionals in both the academic and the clinical environment, and we thank them for their ongoing commitment.

These books would not have been a reality without the dedication and perseverance of the editorial staff. It would be impossible to list all involved at Elsevier that have made the Student and Professional editions possible, but to all we thank you. To Sukanthi and Shruti and the endless emails, we thank you. To Leanne Peters for her patience and exceptional input throughout the project to assist with producing an outstand-ing result, we are especially grateful. Leanne on many occasions was able to provide feedback and assistance that has enhanced the content of both editions. To Natalie Hunt, we thank you for your belief that both of us could achieve this and for your ongoing support through some very diffi cult times, personal loss and a forever-changing environment with COVID-19.

Finally, we would like to thank our families—Glenn, April and Tiffany Monte and Pete, Ben, Sam and Jacob Middleton—who have been there to support and encourage us from the beginning. They have allowed us to spend many hours of family time on this project, and our love and thanks is endless for this.

Lisa SpeedieAndrea Middleton

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C O N T E N T S

SECTION I Children, Their Families and the Nurse

1 Perspectives of Paediatric Nursing, 1Lynne Staff and Lisa Speedie

Healthcare for children, 1Australia’s Health System, 2New Zealand’s Health System, 2

Infant, child and adolescent health promotion, 2Development, 3Nutrition, 3Oral Health, 3

Childhood health problems, 4Obesity and Type 2 Diabetes, 4Childhood Injuries, 4Mental Health Problems, 5Infant Mortality, 6

The art of paediatric nursing, 7Philosophy of Care, 7Role of the Paediatric Nurse, 7

Clinical reasoning and the process of providing nursing care to children and families, 9Clinical Reasoning, 9Nursing Process, 9Quality Outcome Measures, 10

2 Social, Cultural, Religious and Family Influences on Child Health Promotion, 13Julia Laing and Lisa Speedie

General concepts, 13Definition of Family, 13Family Theories, 13Family Nursing Interventions, 15Family Strengths and Functioning Style, 15

Family roles and relationships, 16Parental Roles, 16Role Learning, 16

Parenting, 16Parenting Styles, 16

Special parenting situations, 17Parenting and Relationship Breakdown, 17Single Parenting, 19Parenting in Reconstituted Families, 19Parenting in Dual-earner Families, 19Foster Parenting, 19

Sociocultural influences on children and families, 19

Cultural safety in nursing practice, 20Influences in the surrounding environment, 20

School Communities: School Health and School Connectedness, 20

Schools, 21Peer Cultures, 21Community, 22

Broader influences on child health, 22Social Media and Mass Media, 22Race and Ethnicity, 22Poverty, 23

Land of Origin, Refugee and Immigration, 24Religion/Spiritual Identity, 25

3 Hereditary Influences on Health Promotion of the Child and Family, 29Lisa Speedie

Genetic/genomic nursing competencies, 29Genetics and Genomics, 29Congenital Anomalies, 32Genetic Disorders, 33Single-gene Disorders, 37Variable Patterns of Gene Expression and

Inheritance, 43Mitochondrial Disorders, 43Hereditary Cancer Predisposition Genes, 44

Inborn errors of metabolism, 44Phenylketonuria, 45Cytogenetic Diagnostic Techniques, 47Molecular Diagnostic Techniques, 47Predisposition Genetic Testing, 47Therapeutic Management of Genetic Disease, 48

Impact of hereditary disorders on the family, 48Genetic testing, 48Prenatal Testing, 49Role of Nurses, 51

SECTION II Childhood and Family Assessment

4 Communication, Physical and Developmental Assessment of the Child and Family, 56Andrea Middleton

Guidelines for communication and interviewing, 56Establishing a Setting for Communication, 56Computer Privacy and Applications in Nursing, 56Telephone Triage, Telehealth and Counselling, 56

Communicating with families, 57Communicating with Parents, 57Communicating with Children, 59Communication Techniques, 61

History taking, 63Performing a Health History, 63

Nutritional assessment, 69Dietary Intake, 69Clinical Examination of Nutrition, 69Evaluation of Nutritional Assessment, 73

General approaches towards examining the child, 73Sequence of the Examination, 73Preparation of the Child, 73

Physical examination, 75Growth Measurements, 75Physiological Measurements, 77General Appearance, 80Skin, 80Lymph Nodes, 82Head and Neck, 82Eyes, 82Ears, 85

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xxii CONTENTS

8 Health Problems of the Newborn, 172Tameeka Mulquiney and Sarah Dechert

Birth injuries, 172Soft Tissue Injury, 172Head Injury, 172Fractures, 173Nerve Injuries, 174

Cranial deformities, 175Microcephaly, 175Craniosynostosis, 175Craniofacial Abnormalities, 176Pierre Robin Sequence, 177Cleft Lip and Cleft Palate, 177

Dermatological problems in the newborn, 178Erythema Toxicum Neonatorum, 178Candidiasis, 178Oral Candidiasis, 179Herpes Simplex Virus, 179Bullous Impetigo, 179Birthmarks, 180

Problems related to physiological factors, 180Hyperbilirubinaemia, 180Haemolytic Disease of the Newborn, 184Hypoglycaemia, 187Hyperglycaemia (Transient), 187Hypocalcaemia, 189Haemorrhagic Disease of the Newborn, 189

Problems caused by perinatal environmental factors, 190Chemical Agents, 190Radiation, 190

9 The High-risk Newborn and Family, 192Sarah Dechert, Tameeka Mulquiney & Lisa Speedie

General management of high-risk newborns, 192Identification of High-risk Newborns, 192Intensive Care Facilities, 192

Nursing care of high-risk newborns, 194Assessment, 194Monitoring Physiological Data, 195

High-risk conditions related to dysmaturity, 210Premature Infants, 210Postterm Infants, 212

High risk related to disturbed respiratory function, 212Apnoea of Prematurity, 212Respiratory Distress Syndrome, 213Meconium Aspiration Syndrome, 218Persistent Pulmonary Hypertension of the

Newborn, 219Chronic Lung Disease, 219

High risk related to infectious processes, 221Sepsis, 221

High risk related to cardiovascular and haematological complications, 223Patent Ductus Arteriosus, 223Anaemia, 223Polycythaemia, 226Retinopathy of Prematurity, 226

High risk related to neurological disturbance, 227Perinatal Hypoxic-ischaemic Brain Injury, 227Intracranial Haemorrhage, 227Neonatal/perinatal Stroke, 228Neonatal Seizures, 228

Nose, 88Mouth and Throat, 88Chest, 89Lungs, 91Heart, 92Abdomen, 94Genitalia, 95Anus, 97Back and Extremities, 97Neurological Assessment, 98Developmental Assessment, 101

5 Pain Assessment and Management in Children, 103Maryanne Podham and Patience Moyo

Fundamentals of pain, 103What is pain and how does it occur?, 103What does pain do besides hurt?, 104Common acute pain conditions in children, 104

Needlestick Pain, 106Postoperative Pain, 106

Common chronic pain conditions in children, 106Headaches, 107Abdominal Pain, 107Musculoskeletal Pain, 107Neuropathic Pain Syndromes, 107

Measuring pain in children, 107Observational Pain Measures, 108Special Populations, 108Self-report Pain Rating Scales, 109

Chronic and recurrent pain assessment, 112Multidimensional Measures, 112

Prevention and treatment of pain in children, 112Biobehavioural Interventions, 112Pharmacological Management of Pain, 113

6 Childhood Communicable and Infectious Diseases, 125Andrea Middleton

Infection control, 125Immunisations, 126

Communicable diseases, 132Nursing Care Management, 132Conjunctivitis, 138Stomatitis, 139

Intestinal parasitic diseases, 139General Nursing Care Management, 139

SECTION III Family-centred Care

of the Newborn

7 Health Promotion of the Newborn and Family, 142Tameeka Mulquiney and Amy Vaccaro

Adjustment to extrauterine life, 142Immediate Adjustments, 142Physiological Status of Other Systems, 142

Nursing and midwifery care of the newborn and family, 144Assessment, 144Maintain a Patent Airway, 159Maintain a Stable Body Temperature, 159Protect from Infection and Injury, 159Provide Optimum Nutrition, 161Promote Parent–Infant Bonding (Attachment), 167Prepare for Discharge and Home Care, 168

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xxiiiCONTENTS

Temper Tantrums, 301Stress, 302Regression, 302

Promoting optimum health during toddlerhood, 302Nutrition, 302Sleep and Activity, 304Dental Health, 304Safety Promotion and Injury Prevention, 305Anticipatory Guidance—Care of Families, 308

13 Health Promotion of the Preschooler and Family, 311Emma Collins

Promoting optimum growth and development, 311Biological Development, 311Psychosocial Development, 312Cognitive Development, 313Moral Development (Kohlberg), 313Spiritual Development, 313Development of Body Image, 314Development of Sexuality, 314Social Development, 314Temperament, 318Coping with Concerns Related to Normal Growth

and Development, 318Promoting optimum health during the preschool

years, 322Nutrition, 322Sleep and Activity, 322Oral Healthcare, 322Injury Prevention, 322Anticipatory Guidance—Care of Families, 324

14 Health Problems of Early Childhood, 327Emma Collins

Sleep problems, 327Poisoning, 327

Principles of Emergency Treatment, 328Child maltreatment, 332

Child Neglect, 332Physical Abuse, 332Sexual Abuse, 333Nursing Care of the Maltreated Child, 334

SECTION VI Family-centred Care of the School-age Child

15 Health Promotion of the School-age Child and Family, 341Andrea Middleton

Promoting optimum growth and development, 341Biological Development, 341Cognitive Development (Piaget), 344Moral Development (Kohlberg), 345Language Development, 346Social Development, 346Play, 348Development of Self-concept, 349Development of Sexuality, 352

Coping with concerns related to normal growth and development, 353Discipline, 353Coping with Stress, 354

High risk related to maternal conditions, 230Infants of Diabetic Mothers, 230Drug-exposed Infants, 231Maternal Infections, 234

SECTION IV Family-centred Care of the Infant

10 Health Promotion of the Infant and Family, 239Christine Taylor and Jane Mateer

Promoting optimum growth and development, 239Biological Development, 239Psychosocial Development, 245Cognitive Development, 246Development of Body Image, 248Development of Gender Identity, 248Social Development, 249Temperament, 251Coping with Concerns Related to Normal Growth

and Development, 252Promoting optimum health during infancy, 260

Nutrition, 260Sleep and Activity, 263Dental Health, 264Safety Promotion and Injury Prevention, 264Anticipatory Guidance—Care of Families, 270

11 Health Problems of the Infant, 273Jane Mateer and Christine Taylor

Nutrition in children, 273Obesity, 273

Nutritional imbalances, 274Vitamin Imbalances, 274Mineral Imbalances, 274

Health problems related to nutrition, 275Severe Acute Malnutrition (Protein–energy

Malnutrition), 275Food Sensitivity, 276Faltering Growth, 279

Special health problems, 281Colic (Paroxysmal Abdominal Pain), 281Sudden Infant Death Syndrome, 282Positional Plagiocephaly, 285Brief Resolved Unexplained Event, 286

SECTION V Family-centred Care

of the Toddler and Preschooler

12 Health Promotion of the Toddler and Family, 290Julia Laing

Promoting optimum growth and development, 290Biological Development, 290Cognitive Development, 292Moral Development: Preconventional or Premoral

Level, 295Spiritual Development, 295Development of Body Image, 295Development of Gender Identity, 296Social Development, 296

Temperament, 298Coping with concerns related to normal growth

and development, 298Toilet Training, 298

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xxiv CONTENTS

Endometriosis, 414Premenstrual Syndrome, 414Abnormal Uterine Bleeding, 415Vulvar Pain, 416Vaginal Infections, 416Sexually Transmitted Infections, 417Sexually Transmitted Protozoa Infections, 418Sexually Transmitted Bacterial Infections, 418Sexually Transmitted Viral Infections, 419

Health conditions related to reproduction, 420Adolescent Pregnancy, 420Adolescent Abortion, 421Contraception, 422Sexual Assault (Rape), 424

Health conditions with a behavioural component, 425Anorexia Nervosa and Bulimia Nervosa, 425

Substance abuse, 428Motivation, 428Types of Drugs Abused, 428Tobacco, 428Alcohol, 429Cocaine, 429Narcotics, 429Central Nervous System Depressants, 429Central Nervous System Stimulants, 429Mind-altering Drugs, 429Nursing Care Management, 429

Self-harm, 429Aetiology, 430Diagnostic Evaluation, 430Therapeutic Management, 430

Suicide, 430Aetiology, 430Methods, 430Nursing Care Management, 432

SECTION VIII Family-centred Care of the Child with Special Needs

19 Impact of Chronic Illness, Disability or End-of-life Care for the Child and Family, 435Lisa Speedie

Perspectives on the care of children and families living with or dying from chronic or complex diseases, 435Scope of the Problem, 435Trends in Care, 436

The family of the child with a chronic or complex condition, 437Impact of the Child’s Chronic Illness, 438Coping with Ongoing Stress and Periodic

Crises, 439Assisting Family Members in Managing their

Feelings, 440Establishing a Support System, 441

The child with a chronic or complex condition, 441Developmental Aspects, 441Coping Mechanisms, 442

Nursing care of the family and child with a chronic or complex condition, 444Assessment, 444

Promoting optimum health during the school years, 356Health Behaviours, 356Nutrition, 356Sleep and Rest, 357Physical Activity, 357Dental Health, 359Injury Prevention, 360Anticipatory Guidance—Care of Families, 363

16 Health Problems of the School-age Child, 366Andrea Middleton

Obesity: complications, treatment and prevention, 366Obesity, 366

Dental disorders, 371Dental Decay, 371Trauma, 372

Disorders of continence, 372Enuresis, 372Encopresis, 374

Disorders with behavioural components, 375Attention Deficit/Hyperactivity Disorder, 375Learning Disability, 378Tic Disorders, 378Gilles de la Tourette’s Syndrome, 379Posttraumatic Stress Disorder, 379School Phobia, 380Functional Abdominal Pain, 381Childhood Depression, 382Childhood Schizophrenia, 383Anxiety Disorders, 384Conduct Disorders, 384

SECTION VII Family-centred Care of the Adolescent

17 Health Promotion of the Adolescent and Family, 388Lisa Speedie

Promoting optimum growth and development, 388Biological Development, 388Cognitive Development, 394Development of Value Autonomy, 395Psychosocial Development, 395Social Environments, 398

Promoting optimum health during adolescence, 400Health Concerns of Adolescence, 400Health Promotion Among Special Groups

of Adolescents, 405Nursing Care Management, 407

18 Health Problems of the Adolescent, 411Lisa Speedie

Health conditions of the male reproductive system, 411Penile Conditions, 411Varicocele, 411Epididymitis, 412Testicular Torsion, 412Gynaecomastia, 412

Health conditions of the female reproductive system, 412Gynaecological Examination, 412Menstrual Disorders, 412

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xxvCONTENTS

Stressors and reactions of the family of the child who is hospitalised, 491Parental Reactions, 491Sibling Reactions, 491

Nursing care of the child who is hospitalised, 491Preparation for Hospitalisation, 491Nursing Interventions, 495Supporting Family Members, 499Providing Information, 499Encouraging Parent Participation, 500Preparing for Discharge and Home Care, 500

Care of the child and family in special hospital situations, 501Ambulatory or Outpatient Setting, 501Isolation, 501Emergency Admission, 502Intensive Care Unit, 503

22 Paediatric Nursing Interventions and Skills, 506Deb Surman

General concepts related to paediatric procedures, 506Informed Consent, 506Preparation for Diagnostic and Therapeutic

Procedures, 507Surgical Procedures, 512Compliance, 515

Skin care and general hygiene, 516Maintaining Healthy Skin, 516Bathing, 517Oral Hygiene, 517Hair Care, 518

Feeding the sick child, 518Controlling elevated temperatures, 519

Therapeutic Management, 519Family Teaching and Home Care, 520

Safety, 520Environmental Factors, 520Infection Control, 521Transporting Infants and Children, 522Restraining Methods, 523

Positioning for procedures, 524Femoral Venepuncture, 524Extremity Venepuncture or Injection, 524Lumbar Puncture, 525Bone Marrow Aspiration or Biopsy, 525

Collection of specimens, 525Fundamental Steps Common to All Procedures, 525Urine Specimens, 525Stool Specimens, 527Blood Specimens, 528Respiratory Secretion Specimens, 529

Administration of medication, 530Determination of Drug Dosage, 530Oral Administration, 530Intramuscular Administration, 532Subcutaneous and Intradermal Administration, 535Intravenous Administration, 535

Maintaining fluid balance, 537Measurement of Intake and Output, 537Parenteral Fluid Therapy, 538Securement of a Peripheral Intravenous Line, 538Safety Catheters and Needleless Systems, 539Infusion pumps, 539

Provide Support at the Time of Diagnosis, 444Support the Family’s Coping Methods, 445Educate about the Disorder and General

Healthcare, 446Promote Normal Development, 447Establish Realistic Future Goals, 448

Palliative care in childhood terminal illness, 448Scope of the Problem, 448Principles of Palliative Care, 448Goals of Care, 449Awareness of Dying in Children with Life-

threatening Illness, 450Children’s Understanding of and Reactions

to Dying, 450Delivery of Palliative Care Services, 453

Nursing care of the child and family at the end of life, 453Management of Pain and Suffering, 453Parents’ and Siblings’ need for Education and

Support through the Caregiving Process, 454Care at the Time of Death, 456Care of the Family Experiencing Unexpected

Childhood Death, 458Special decisions at the time of dying and death, 458

Advance Care Planning, 458Viewing of the Body, 459Organ or Tissue Donation and Autopsy, 459Siblings’ Attendance at Funeral Services, 459

Care of the grieving family, 459Grief, 460Mourning, 461

The nurse and the child with life-threatening illness, 463Nurses’ Reactions to Caring for Children with

Life-threatening Illnesses, 463Coping with Stress, 464

20 Impact of Cognitive or Sensory Loss on the Child and Family, 468Andrea Middleton

Cognitive disability, 468General Concepts, 468

Nursing care of children with impaired cognitive function, 469Educate Child and Family, 469Down Syndrome, 472Fragile X Syndrome, 474

Sensory loss, 474Deafness and Hard of Hearing, 474Blindness and Low Vision, 478Hearing Loss and Low Vision, 482

Communication difficulties, 482Autism Spectrum Disorders, 482

SECTION IX The Child Who is Hospitalised

21 Family-centred Care of the Child During Illness and Hospitalisation, 488Deb Surman and Julia Laing

Stressors of hospitalisation and children’s reactions, 488Separation Anxiety, 488Loss of Control, 490Effects of Hospitalisation on the Child, 490

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Renal Tubular Acidosis, 610Nephrogenic Diabetes Insipidus, 610

Miscellaneous renal disorders, 610Renal Trauma, 610Renal Failure, 611Chronic Kidney Disease, 611

Renal replacement therapy, 613Haemodialysis, 613Peritoneal Dialysis, 614Continuous Venovenous Haemofiltration, 615Transplantation, 615

Defects of the genitourinary tract, 616Phimosis, 616Hydrocele, 616Cryptorchidism, 617Hypospadias, 617

Disorders of sex development, 618Pathophysiology, 618Therapeutic Management, 618Family Support, 618

25 The Child with Gastrointestinal Dysfunction, 620Lisa Speedie

Gastrointestinal structure and function, 620Development of the Gastrointestinal Tract, 620Digestion, 621Absorption, 621Assessment of Gastrointestinal Function, 623

Gastrointestinal disorders, 623Diarrhoea, 623Constipation, 631Vomiting, 632

Ingestion of foreign substances, 633Foreign Bodies, 633

Disorders of motility, 634Hirschsprung’s Disease (Congenital Aganglionic

Megacolon), 634Gastro-oesophageal Reflux, 635Irritable Bowel Syndrome, 637

Inflammatory conditions, 637Acute Appendicitis, 637Meckel’s Diverticulum, 640Inflammatory Bowel Disease, 641

Obstructive disorders, 644Hypertrophic Pyloric Stenosis, 644Intussusception, 645

Malabsorption syndromes, 647Coeliac Disease (Gluten-sensitive Enteropathy), 647

Hepatic disorders, 648Acute Hepatitis, 648Cirrhosis, 651

Hernias, 651Umbilical Hernia, 651Inguinal Hernia, 652Femoral Hernia, 653Anorectal Malformations, 653

SECTION XI Childhood Oxygenation Problems

26 The Child with Respiratory Dysfunction, 657Kylie Smith and Felicity Radford

Introduction, 657Respiratory tract structure, 657

Respiratory Function, 658

Maintenance, 539Complications, 540Removal of a Peripheral Intravenous Line, 540Rectal Administration, 540Optic, Otic and Nasal Administration, 541Aerosol Therapy, 542Family Teaching and Home Care, 542Nasogastric, Orogastric and Gastrostomy

Administration, 542Alternative feeding techniques, 543

Gavage Feeding, 543Gastrostomy Feeding, 545Nasoduodenal and Nasojejunal Tubes, 546Total Parenteral Nutrition, 546Family Teaching and Home Care, 547

Procedures related to elimination, 547Enema, 547Ostomies, 547Family Teaching and Home Care, 548

SECTION X Childhood Nutrition and Elimination Problems

23 The Child with Fluid and Electrolyte Imbalance, 552Patience Mayo

Introduction, 552Distribution of body fluids, 552

Water Balance, 552Disturbances of fluid and electrolyte balance, 555

Dehydration, 558Water Intoxication, 561Oedema, 561

Nursing responsibilities in fluid and electrolyte disturbances, 562Assessment, 563Shock, 563Septic Shock, 567Anaphylaxis, 569Toxic Shock Syndrome, 572

Burns, 572Overview, 572Burn Wound Characteristics, 573Pathophysiology, 575Therapeutic Management, 580Nursing Care Management, 586

24 The Child with Renal Dysfunction, 593Lisa Speedie

Renal structure and function, 593Renal Physiology, 593Renal Pelvis and Ureters: Structure and

Function, 595Urethrovesical Unit: Structure and

Function, 595Genitourinary tract disorders, 600

Urinary Tract Infection, 600Vesicoureteral Reflux, 603

Glomerular disease, 604Acute Glomerulonephritis, 604Chronic or Progressive Glomerulonephritis, 607Nephrotic Syndrome, 608

Renal tubular disorders, 610Tubular Function, 610

Sample

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xxviiCONTENTS

Altered Haemodynamics, 722Clinical Consequences of Congenital Heart

Disease, 723Congestive Heart Failure, 723Nursing Care of the Child with Congenital Heart

Disease and Their Family, 733Acquired cardiovascular disorders, 738

Infective Endocarditis, 739Acute Rheumatic Fever and Rheumatic Heart

Disease, 740Cultural Considerations, 742Kawasaki Disease, 742Systemic Hypertension, 745Pulmonary Hypertension, 748Cardiomyopathy, 749

28 The Child with Haematological or Immunological Dysfunction, 753Julia Laing

The haematological system and its function, 753Origin of Formed Elements, 753Assessment of Haematological Function, 756

Red blood cell disorders, 756Anaemia, 756Blood Transfusion Therapy, 759

Anaemia caused by nutritional deficiencies, 761Iron Deficiency Anaemia (IDA), 761Defects in Haemostasis, 764Mechanisms Involved in Normal

Haemostasis, 765Haemophilia, 765

Other haematological disorders, 768Neutropenia, 768

Immunological deficiency disorders, 768Mechanisms Involved in Immunity, 768Human Immunodeficiency Virus Infection and

Acquired Immunodeficiency Syndrome, 769

SECTION XIII Childhood Regulatory Problems

29 The Child with Cancer, 773Elyce Kenny

Cancer in children, 773Epidemiology, 773Aetiology, 774Diagnostic Evaluation, 774Clinical Trials, 776Treatment Modalities, 777Complications of Therapy, 780

Nursing care management, 780Signs and Symptoms of Cancer in Children, 781Managing Side Effects of Treatment, 781Preparation for Procedures, 784Pain Management, 785Health Promotion, 785Family Education, 785Completion of Therapy, 786

Cancers of blood and lymph systems, 786Acute Leukaemias, 786Lymphomas, 789

Nervous system tumours, 791Brain Tumours, 791

The childhood cancer survivor, 795

Defences of the respiratory tract, 658Assessment of respiratory function, 659

Physical Assessment, 659Diagnostic Procedures, 659

General aspects of respiratory tract infections, 660Aetiology and Characteristics, 660Clinical Manifestations, 661Nursing Care of the Child with a Respiratory Tract

Infection, 662Upper respiratory tract infections (URTI), 664

Acute Viral Nasopharyngitis, 664Acute Streptococcal Pharyngitis, 665Tonsillitis, 666Glandular Fever (Infectious Mononucleosis), 668Influenza, 669Coronavirus (COVID-19), 670Otitis Media, 670Acute Otitis Externa, 673

Croup syndromes, 673Acute Epiglottitis, 674Acute Laryngitis, 675Acute Laryngotracheobronchitis (Croup), 675Acute Spasmodic Laryngitis, 677Bacterial Tracheitis, 677

Infections of the lower airways, 677Bronchitis, 677Respiratory Syncytial Virus (RSV)

and Bronchiolitis, 677Pneumonia, 680Viral Pneumonia, 680Primary Atypical Pneumonia, 680Bacterial Pneumonia, 681Neonatal Pneumonia, 683

Other infections of the respiratory tract, 683Pertussis (Whooping Cough), 683Tuberculosis, 683

Respiratory disturbance caused by non-infectious irritants, 685Foreign Body Ingestion and Aspiration, 685Foreign Body in the Nose, 687Aspiration Pneumonia, 687Smoke Inhalation Injury, 688Environmental Tobacco Exposure, 690

Long-term respiratory dysfunction, 690Asthma, 692Cystic Fibrosis, 705Obstructive Sleep Apnoea, 712

Respiratory emergency, 712Respiratory Failure, 712Nursing Care Management, 713

SECTION XII Childhood Blood Production and Circulation Problems

27 The Child with Cardiovascular Dysfunction, 717Lauren Kendrick

Cardiac structure and function, 717Cardiac Development and Function, 717Assessment of Cardiac Function, 720Tests of Cardiac Function, 721Congenital Heart Disease, 722

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xxviii CONTENTS

Viral Infections, 871Dermatophytoses (Fungal Infections), 872Systemic Mycotic (Fungal) Infections, 875

Skin disorders related to chemical or physical contacts, 875Contact Dermatitis, 875Allergic Contact Dermatitis to Plants, 876Drug Reactions, 876

Skin disorders related to animal contacts, 877Arthropod Bites and Stings, 877Scabies, 877Pediculosis Capitis, 879Rickettsial Diseases, 880Animal Bites, 881Human Bites, 881Cat-scratch Disease, 881Flying Fox (Bat) Bites, 882

Miscellaneous skin disorders, 882Skin disorders associated with specific age

groups, 882Nappy Rash, 882Atopic Dermatitis (Eczema), 884Seborrhoeic Dermatitis, 886Acne, 886

Cold injury, 888 33 The Child with Musculoskeletal or Articular

Dysfunction, 890Patience Moyo

The child and trauma, 890Trauma Management, 890

The immobilised child, 893Immobilisation, 893The Child in a Cast, 900The Child in Traction, 902Distraction, 904Amputation, 905Mobilisation Devices, 905

The child with a fracture, 907Fracture Complications, 912

Injuries and health problems related to sports participation, 914Preparation for Sports, 914Types of Injury, 914Contusions, 915Dislocations, 915Sprains and Strains, 916Overuse Injury, 916Exercise-induced Heat Stress, 917Health Concerns Associated with Sports, 918Nurse’s Role in Children’s Sports, 920

Musculoskeletal dysfunction, 920Torticollis, 920Kyphosis and Lordosis, 920Idiopathic Scoliosis, 921Skeletal Limb Deficiency, 923Developmental Dysplasia of the Hip, 924Legg-Calvé-Perthes Disease, 927Slipped Capital Femoral Epiphysis, 927Metatarsus Adductus, 928Congenital Talipes Equinovarus

(Clubfoot), 928Nursing Care Management, 929

30 The Child with Cerebral Dysfunction, 799Emma Collins

Cerebral structure and function, 799Development of the Neurological System, 799Central Nervous System, 799Increased Intracranial Pressure, 801

Evaluation of neurological status, 802Assessment: General Aspects, 802Altered States of Consciousness, 803Neurological Examination, 804Special Diagnostic Procedures, 806

The child with cerebral compromise, 808Head Injury, 808Submersion Injury, 815

The child with cerebral malformation, 816Hydrocephalus, 816

Intracranial infections, 820Bacterial Meningitis, 820Non-bacterial (Aseptic) Meningitis, 823

Seizures and epilepsy, 823Epilepsy, 823

Headache, 832Assessment, 832Migraine Headache, 833

31 The Child with Endocrine Dysfunction, 837Lisa Speedie

The endocrine system, 837Hormones, 837Neuroendocrine Interrelationships, 837

Disorders of pituitary function, 838Hypopituitarism, 838Pituitary Hyperfunction, 842Precocious Puberty, 842Diabetes Insipidus, 843

Disorders of thyroid function, 844Juvenile Hypothyroidism, 845Goitre, 845Chronic Lymphocytic Thyroiditis, 845Hyperthyroidism, 846

Disorders of parathyroid function, 847Hypoparathyroidism, 847Hyperparathyroidism, 848

Disorders of adrenal function, 848Adrenal Hormones, 848Chronic Adrenocortical Insufficiency

(Addison’s Disease), 849Cushing’s Syndrome, 850Congenital Adrenal Hyperplasia, 852

Disorders of pancreatic hormone secretion, 852Diabetes Mellitus, 852

SECTION XIV Childhood Physical Mobility Problems

32 The Child with Integumentary Dysfunction, 864Ibi Patane

Integumentary dysfunction, 864Skin Lesions, 864Wounds, 865

Infections of the skin, 871Bacterial Infections, 871

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xxixCONTENTS

Cerebral Palsy, 943Hypotonia, 950Spinal Muscular Atrophy Type 1 (Werdnig-

Hoffmann Disease), 950Juvenile Spinal Muscular Atrophy (Kugelberg-

Welander Disease), 952Spinal Cord Injuries, 952

Muscular dysfunction, 962Muscular Dystrophies, 962Duchenne’s Muscular Dystrophy, 963

Orthopaedic infections, 929Osteomyelitis, 929Septic Arthritis, 931Skeletal Tuberculosis, 931

Skeletal and articular dysfunction, 931Osteogenesis Imperfecta, 931Juvenile Idiopathic Arthritis, 932Systemic Lupus Erythematosus, 936

34 The Child with Neuromuscular or Muscular Dysfunction, 942Andrea Middleton

Neuromuscular dysfunction, 942Classification and Diagnosis, 942

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• Understand clinical reasoning and critical thinking in paediatric nursing

L E A R N I N G O B J E C T I V E S

to 3.3 per 1000 live births between 1997 and 2017 (AIHW 2020), and in New Zealand, reduced from 5 per 1000 live births in 2008 to 3.8 per 1000 live births in 2018 (Ministry of Health 2019a).

Despite these positive advances in infant health, reports in Austra-lia and New Zealand (see, for example, Australia’s children: in brief [AIHW 2019] and the Annual Update of Key Results 2019/20: New Zealand Health Survey [Ministry of Health 2020d]) identifi ed a num-ber of areas for improvement. For example, 1 in 4 Australian children aged 5 to 14 years are classifi ed as overweight or obese, and obesity among children in New Zealand varied by ethnicity as follows: Pacifi c (29.1%), Māori (13.2%), Asian (3.4%) and European/Other (7.2%). Accidental injury remains a frequent cause of hospitalisation, and 1 in 5 Australian 9-year-old children reported experiencing bullying on a weekly basis in 2015 (AIHW 2019). This report also highlighted that the majority of 12- to 13-year-old children (97%) had someone they could talk to if they had a problem with poor health, and this was identifi ed by children aged 9 to 13 years as important, second to fam-ily, for having a good life. Similarly, in 2019 the Education Review Offi ce in New Zealand reported that 46% of primary school students and 31% of secondary school students reported that they had experienced bullying.

In Australia, the AIHW collects, collates, regularly updates and presents statistical health and welfare data. Relevant to infant health and wellbeing are the Children’s Headline Indicators (CHIs) outlined in Box 1.1 . In 2008 the CHIs were endorsed at the Australian Health Ministers’ Conference, the Community and Disability Services Minis-ters’ Conference and the Australian Education, Early Childhood Devel-opment and Youth Affairs Senior Offi cials Committee in 2008. First reported in 2009, the CHIs are 19 high-level measurable indicators that identify the fundamental effect of immediate environment as a key infl uence on children’s health, development and wellbeing. The CHIs are assembled into three general topic areas: health; early learning and care; and family and community.

The structure of the health systems in Australia and New Zealand is also worthy to note for those involved in paediatric nursing, as this

HEALTHCARE FOR CHILDREN The major goal for paediatric nursing is to enable children’s wellbeing by providing access to quality healthcare for children and their fami-lies. While childhood is a time of rapid growth and development where health behaviours are established, it is also a time of vulnerabil-ity. Many health problems experienced by adults originate in infancy and childhood, and early intervention can prevent later illnesses. Key indicators known to infl uence a person’s long-term wellbeing are healthcare availability, access and uptake, where a child lives, their family’s culture and social circumstances, lifestyle, community and environment.

To begin to appreciate the concept of infant, child and adolescent health and wellbeing, a brief examination of some background data is warranted. In 2017, Australia’s population was 23.5 million people, with children making up just over 19% of the population, or 4.7 mil-lion (Australian Bureau of Statistics 2018). In New Zealand, the total population according to the 2013 Census data was 4.475 million peo-ple. Of these, 25%, or 1.12 million, were children under the age of 18 years (Offi ce of the Children’s Commissioner 2016).

Understanding the determinants of health and the healthcare needs of this proportion of the population is fundamental in terms of plan-ning, infrastructure and provision of current and future health ser-vices. For example, in Australia, immunisation rates for all children have increased. In 2019, 94.2% of 1-year-old, 91.4% of 2-year-old and 94.8% of 5-year-old Australian children were fully immunised (Aus-tralian Government Department of Health 2020). However, in New Zealand, the 2019 immunisation rates for 1-, 2- and 5-year-old chil-dren have decreased by 92%, 91% and 88% respectively (Ministry of Health 2019b). The percentage of women smoking in the fi rst 20 weeks of pregnancy in Australia has decreased from 13% in 2011 to 11% in 2015 (Australian Institute for Health and Welfare [AIHW] 2020) and in New Zealand, 13% of pregnant women smoked in 2017, compared to 16% in 2008 (Ministry of Health 2014, Smokefree Aotearoa 2025 2017). Similarly, the infant death rate in Australia has reduced from 5.0

SECTION I Children, Their Families and the Nurse

1

Perspectives of Paediatric Nursing Lynne Staff and Lisa Speedie

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2 SECTION I Children, Their Families and the Nurse

some paediatric services/procedures may only be covered by a private specialist.

There are two types of private health insurance cover: 1. hospital cover (taken out for in-hospital treatment) 2. ancillary or ‘extras’ cover (taken out for ambulance, optometry,

dental, physiotherapy and other ancillary services). Private health insurance may cover full or partial costs of certain

treatments for private patients, and privately insured patients may choose to be cared for in private or public hospitals, with a medical practitioner of their choice. Private health insurance may also cover some additional services that Medicare does not; for example, dental, optical, physiotherapy and chiropractic care costs.

New Zealand’s Health System Similar to Australia, New Zealand’s health and disability services are also provided by a complex network of organisations and people who work together across the system to attain better health for New Zealanders, and public and private health services are available.

The public health system is funded by taxpayers as well as the Accident Compensation Corporation (ACC) and several government agencies. Essential healthcare services are available at no cost for all New Zealand citizens and also to people on a work permit valid for 2 years or longer. Overseas visitors from countries with respective re-ciprocal health agreements (e.g. Australia and the United Kingdom) can also access some services. The public system uses a community-focused model, comprising three key sectors. These are the district health boards (DHBs), primary health care and primary health or-ganisations (PHOs). DHBs are government funded and overarch PHOs. They provide and fund health and disability services in their district whereas PHOs coordinate local collaborative primary health services. Primary health care includes fi rst-level services (e.g. GP ser-vices) and mobile nursing and community health services. The public healthcare system in New Zealand gives permanent residents access to free or heavily subsidised hospital care, as well as emergency treatment.

The ACC is another element of the system. ACC is the New Zealand Government’s personal injury organisation which assists medical and treatment fees payment, and rehabilitation and residential care costs caused by an accident or injury.

Private healthcare services, including private hospitals or clinics, are not funded by the government and are based on a user-pays scheme. Private healthcare services offer non-urgent and elective treat-ments, and private accident, emergency and medical clinics provide out-of-hours services outside of the public system. Specialists often work across private and public services, and there are also privately owned screening and diagnostic services. As in Australia, patients with private health insurance are able to utilise public or private hospital care and are able to choose their medical care provider.

The two types of private healthcare policies are: 1. ‘comprehensive cover’ that cover all medical costs, including GP

visits and prescriptions 2. those that cover combinations of specialist care and elective (non-

urgent) surgery. The Pharmaceutical Management Agency (PHARMAC) was estab-

lished by the New Zealand Government in 1983. This agency makes subsidised medications available and negotiates low medication prices.

INFANT, CHILD AND ADOLESCENT HEALTH PROMOTION Child health promotion provides opportunities to reduce differences in current health status among members of different groups and to ensure equal opportunities and resources to enable all children to

is relevant to the availability of, access to and affordability of services, and how health services are organised, offered and provided.

Australia’s Health System Australia’s health system has been described as an intricate arrange-ment of public and private providers, settings, services and support mechanisms (AIHW 2020). Australia’s public health system, Medicare, is funded by Australian taxpayers and is made up of the Medicare Benefi ts Schedule (MBS) which covers health services and hospital care, and the Pharmaceutical Benefi ts Scheme (PBS) which covers prescribed medications. Those who may access Medicare services include Australian citizens and residents, and individuals from a coun-try which has a reciprocal health service agreement with Australia (e.g. the United Kingdom). The MBS provides full or partial cover for medi-cal services provided to healthcare users who are registered with the system and who hold a Medicare card. These include general practitio-ner (GP) billing costs, hospitalisation costs and some diagnostic and screening costs. While the PBS reduces the cost of many medications for the public, many more medications are not listed on the PBS and incur signifi cant out-of-pocket expenses for the healthcare user. Similarly, patients who require ongoing screening, tests and treatments may also incur signifi cant healthcare expenses. To help address this, the Medicare Safety Net was established to support people with health issues that incur high and ongoing health and pharmaceutical expenses.

Patients may be bulk billed (where the cost is covered by Medicare) or privately billed (where they are charged a fee that is usually more than the Medicare rebate). Mixed billing is the term used when the patient is charged for and pays the entire fee upfront but a rebate from Medicare can be claimed at a later date.

Because Medicare does not cover all medical services, many people take out private healthcare insurance; however, the number of people taking out private health insurance is decreasing. In December 2019, 40% of Australian citizens held private health insurance compared to 47.3% in December 2014 (Australian Prudential Regulation Authority [APRA] 2020). The demographics of the person who holds private health insurance is also changing with fewer people having insurance, but their use of services is increasing (APRA 2020). Many Australian children are covered by their parents’ private health insurance, and

Health Smoking and drug use during pregnancy Infant mortality Low birthweight Breastfeeding Immunisation Overweight and obesity Dental health Injury deaths Teenage births

Early learning and care Early childhood education Transition to primary school Attendance at primary school Literacy Numeracy

Family and community Family social network Family economic situation Child abuse and neglect Social and Emotional wellbeing Shelter

BOX 1.1 Australian Institute of Health and Welfare Children’s Headline Indicator list

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3CHAPTER 1 Perspectives of Paediatric Nursing

maturity is an important consideration for health professionals when caring for them throughout this developmental period. Investment in the early years of a person’s life, coupled with the benefi ts of early intervention (should it be required), demonstrate a positive cumula-tive effect on health in the long term (Australian Health Minister’s Advisory Council 2015).

An important example for health promotion during early child development is to be aware of changing recommendations that address the fast-changing world of technology in our society. An important example is the changes in recommendations on screen viewing by in-fants and children. For infants less than 18 months of age, no screen time is recommended except for video calling with a grandparent or loved one, yet Tooth et al (2019) found in their study of Australian children that infants up to 12 months of age were having 50 and 58 minutes of screen time on weekdays and weekend days respectively. Parents should be advised to use technology sparingly before 5 years of age and to always participate during screen time viewing.

Nutrition Nutrition is an essential component for healthy growth and develop-ment. Human milk is the preferred form of nutrition for all infants and exclusive breastfeeding is recommended for all infants at least up to 6 months of age (Council of Australian Governments [COAG] Health Council 2019). Breastfeeding provides the infant with micronutrients, immunological properties and several enzymes that enhance digestion and absorption of these nutrients. A recent resurgence in breastfeeding has occurred as a result of the education of parents regarding its bene-fi ts and increased social support for breastfeeding women. However, there are still many infants who are never breastfed, or breastfed for a very limited time, and whose health suffers because of this. The signifi -cance of breastfeeding to the overall health of the infant and child and the ongoing benefi ts to health throughout the lifespan, because of having been breastfed as an infant, are still being discovered.

Children establish lifelong eating habits during the fi rst 3 years of life, and the nurse is ideally positioned to support and educate parents on the importance of nutrition. Most eating preferences and attitudes related to food develop from family infl uences and culture. During adolescence, parental infl uence diminishes and the adolescent makes food choices related to independent decision-making, peer acceptabil-ity and sociability. Many food choices can be detrimental to adoles-cents who have chronic illnesses including, but not limited to, diabetes, obesity, anorexia nervosa, binge eating disorder, chronic lung disease, hypertension, cardiovascular risk factors and renal disease. The impor-tance of good nutrition balanced with regular exercise cannot be underscored enough.

Families that struggle with lower incomes, who live in remote and very remote communities, who experience homelessness or overcrowd-ing, and who have migrant status may lack the resources and knowledge to provide their children with adequate and nutritious foods including fresh fruits and vegetables, and appropriate protein foods (Lee et al 2018). The result can be nutritional defi ciencies with subsequent growth and developmental delays, depression and behaviour problems.

Oral Health Oral health is an essential component of overall health, and should be a key feature of health promotion throughout infancy, childhood and adolescence. Preventing dental caries and developing healthy oral hygiene habits must occur early in childhood. Dental caries have been recognised for decades as a signifi cant yet preventable health problem for children (Clark et al 2015). Children in racial or cultural minority groups experience disparities in oral healthcare and are much more likely to have dental disease. Australian Indigenous children ages 2 to

achieve their fullest health potential. Health indicators provide a back-ground by identifying essential components to enable child health promotion programs to be designed to prevent future health problems in children in Australia and New Zealand. According to Aotearoa’s Te Hiringa Hauora/Health Promotion Agency, health promotion initiatives encompass:

• promotion of health and wellbeing and encouragement of healthy lifestyles

• prevention of disease, illness and injury • enabling environments that support health, wellbeing and

healthy lifestyles • reduction of personal, social and economic harm.

(Aotearoa Te Hiringa Hauora/Health Promotion Agency 2018)

The National Action Plan for the Health of Children and Young People 2020-2030 was developed by the Australian Government’s Department of Health in 2020 as a foundation for the formulation and enactment of a series of policies, interventions and approaches with the purpose of improving health outcomes for children and young people. Five priority areas were identifi ed as essential to drive change and improve outcomes so that the health of Australia’s children and young people is maximised. The fi ve priority areas in the action plan are to: 1. improve health equity across populations 2. empower parents and caregivers to maximise healthy development 3. tackle mental health and risky behaviours 4. address chronic conditions and preventive health 5. strengthen the workforce.

Healthy Kids and Go4Fun are examples of Australian child health promotion initiatives with an overarching goal to improve the health of Australia’s children. Major themes of these initiatives are promoting family support, child development, mental health and healthy nutri-tion. These support the development of healthy weight, physical activ-ity, oral health, healthy sexual development and sexual identity, safety and injury prevention, and an understanding of the importance of community relationships and resources. Developmentally appropriate health promotion strategies are discussed throughout this book. Key examples of child health promotion themes that are essential for all age groups include promoting development, nutrition and oral health. Recommendations for preventive health and primary healthcare dur-ing infancy, early childhood and adolescence are found in Chapters 7, 10, 12, 13, 15 and 17.

Development Health promotion recognises the physical, psychological and emo-tional changes that occur in human beings in the period before birth until the end of adolescence. Developmental processes are unique to each stage of development, and continuous screening and assessment are adjuncts to enable early intervention when problems are found. The most dramatic times of physical, motor, cognitive, emotional and social development occur before birth and during infancy. Interactions between the parent and infant are central to promoting optimal devel-opmental outcomes and are a key component of infant assessment. During early childhood, early identifi cation of developmental delays is critical for establishing early interventions. Health promotion accom-panied by the provision of timely and age- and family-appropriate education can help to ensure that parents are aware of the specifi c needs of each developmental stage of their child. Ongoing observation and screening during middle childhood provides opportunities to positively develop and strengthen cognitive and emotional attributes, communication skills, self-esteem and independence. Recognition that adolescents differ greatly in their physical, social and emotional

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4 SECTION I Children, Their Families and the Nurse

as a body mass index (BMI) at or greater than the 95th percentile for youth of the same age and gender. Overweight is defi ned as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex.

Increasing evidence associates maternal obesity as a major infl u-ence on offspring health during childhood and in adult life (Godfrey et al 2017). An optimal nutritional and microbial environment during pregnancy may reduce the risk of infants being obese or overweight during early life (Haszard et al 2019).

Lack of physical activity related to limited resources, unsafe environments and inconvenient play and exercise facilities, com-bined with easy access to television and video games, increases the incidence of obesity among children from low-income backgrounds and minority groups (AIHW 2020). Overweight youth have in-creased risk for cardiometabolic changes (a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, dys-lipidaemia and abdominal obesity) in the future (Weiss et al 2013, AIHW 2020) ( Fig 1.1 ).

Children aged 5 to 14 years and living in the rural and remote en-vironments are more likely to be overweight or obese than those living in metropolitan cities (AIHW 2020) ( Fig 1.2 ). It is recommended that nurses begin with prevention strategies focusing on reducing the inci-dence of overweight as early as possible, educating about nutrition and obesity in infancy (AIHW 2020).

Childhood Injuries Injuries are the most common cause of death and disability to children in Australia (AIHW 2020). For New Zealand it was transport and assault (Ministry of Health 2019c, 2020c).

In Australia and New Zealand, injury is a major cause of death and hospitalisation. Children are vulnerable to certain types of injuries depending on their age, and this is refl ected by their stage of develop-ment. Very young children are more vulnerable to injury where they are not yet able to assess the potential dangers. Injuries among older children are increasingly infl uenced by risk-taking behaviour and peers (AIHW: Pointer 2014).

8 years are twice as likely to experience any dental caries in primary teeth compared with non-Indigenous children (Baker et al 2018).

Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children (Baker & Edlund 2018). Early childhood caries is a preventable disease, and nurses play an essential role in health promotion and health edu-cation in relation to practising dental hygiene (beginning with the fi rst tooth eruption), drinking fl uoridated water and instituting early den-tal preventive care. Oral healthcare practices established during the early years of development prevent destructive periodontal disease and dental decay.

CHILDHOOD HEALTH PROBLEMS Changes in modern society, including pandemics, advancing medical knowledge and technology, the proliferation of information systems, economically troubled times, and various changes and disruptive infl uences on the family, are leading to signifi cant medical problems that affect the health of children. Problems that can negatively affect a child’s development include poverty, violence, aggression, non-compliance, school failure and adjustment to parental separation and divorce. In addition, mental health issues cause challenges in child-hood and adolescence. Recent concern has focused on groups of children who are at highest risk, such as children born preterm or with a very low birth weight (VLBW) or low birth weight (LBW), children attending childcare centres, children who live in poverty or are homeless and children with chronic medical issues and disabili-ties. In addition, these children and their families face multiple bar-riers to adequate health, dental and mental healthcare. A perspective of several health problems facing children and the major challenges for paediatric nurses is discussed in the following sections.

Obesity and Type 2 Diabetes Childhood obesity, the most common nutritional problem among children in Australia and New Zealand, is increasing in epidemic pro-portions (AIHW 2020). Obesity in children and adolescents is defi ned

Fig 1.1 Overweight or obese children aged 5–14, Australia, 2007–08 to 2017–18 [2]. (Source: Australian Insti-tute of Health and Welfare (AIHW). (2020). Australia’s children. 3 April. AIHW, Canberra. https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/health-australias-children . Data from: Australian Bureau of Statistics (ABS). (2019). Microdata: National Health Survey, 2017–18. ABS cat. no. 4324.0.55.001. Canberra: ABS. Customised data report; AIHW 2017. A picture of overweight and obesity in Australia 2017. Cat. no. PHE 216. AIHW, Canberra.)

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5CHAPTER 1 Perspectives of Paediatric Nursing

The child’s developmental stage partially determines the types of injuries that are most likely to occur at a specifi c age and helps provide clues to preventive measures. For example, small infants are helpless in any environment. When they begin to roll over or propel themselves, they can fall from unprotected surfaces. The crawling infant, who has a natural tendency to place objects in the mouth, is at risk for aspira-tion or poisoning. The mobile toddler, with the instinct to explore and investigate and the ability to run and climb, may experience falls, burns or collisions with objects. As children grow older, their absorption with play makes them oblivious to environmental hazards such as street traffi c or water. The need to conform and gain acceptance compels older children and adolescents to accept challenges and dares. Although the rate of injuries is high in children younger than 9 years, most fatal injuries occur in later childhood and adolescence.

The pattern of deaths caused by unintentional injuries, especially from motor vehicle crashes (MVCs), drowning and burns, is remark-ably consistent in most Western societies. In Australia, the leading causes of death from injuries for each age group according to gender are presented in Figure 1.3 . The majority of deaths from injuries occur in boys. Fortunately, prevention strategies such as car restraints, bicycle helmets, sleeping positions and smoke detectors have signifi cantly decreased fatalities for children.

Bicycle-associated injuries also cause a number of childhood deaths. Community-wide bicycle helmet campaigns and mandatory-use laws have resulted in signifi cant increases in helmet use. Still, issues such as stylishness, comfort and social acceptability remain important factors in non-compliance. Nurses can educate children and families about pedestrian and bicycle safety.

Mental Health Problems In Australia in 2013–14, an estimated 314,000 children aged 4 to 11 years (almost 14%) experienced a mental disorder. Boys were more commonly affected than girls (17% compared with 11%). Attention defi cit hyperactivity disorder (ADHD) was the most common disorder

COMMUNITY FOCUS

Children can be exposed to or experience crime as victims or they can witness crime within their home or the broader community. Exposure of any kind at a young age can have potentially detrimental impacts on a child’s health, safety and development (Australia’s National Research Organisation for Women’s Safety [ANROWS] 2018, World Health Organization [WHO] 2016). This expo-sure can be a single time or multiple times and the exposure to crime can vary from non-violent crime, such as theft or fraud, to highly violent crime, such as aggravated sexual assault or homicide (ANROWS 2018).

There can be both short- and long-term physical and/or emotional impacts for children who are victims of, or witnesses to, crime. Examples of short-term impacts are a broken bone, temporary emotional regression (such as guilt) or behaviour regression; however, in many cases, the consequences can have long-term effects and lead to developmental, mental, physical and social issues (ANROWS 2018, Finkelhor et al 2009, Lewis et al 2010, WHO 2016). For example, children exposed to crime, especially violent crime or crime involving weapons, may have increased mental health issues such as depression, suicide ideations, diffi culty regulating emotions and behaviour, poor relation-ships and social interactions, or suffer bullying and homelessness (Bland & Shallcross 2015, Campo 2015, Jaffe et al 2012, Knight 2015, Lewis et al 2010, Mitchell et al 2015).

Fig 1.2 Proportion (%) of children aged 5–14 who were overweight or obese, by priority population groups, Australia, 2017–18. (a) Regional and remote includes Inner regional , Outer regional and Remote areas. Very remote areas were excluded from the survey. (Source: Australian Institute of Health and Welfare (AIHW). (2020). Australia’s children. 3 April. AIHW, Canberra. https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/health-australias-children . Data from ABS 2019.)

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6 SECTION I Children, Their Families and the Nurse

non-Indigenous child deaths (ages 0 to 4 years) by 2018 was a key priority of the Closing the Gap framework established by COAG in 2008.

In New Zealand, one major factor leading to high rates of infant death is sudden unexpected death in infancy (SUDI). Rates for ba-bies in the Māori and Pacific peoples ethnic groups were higher than the rates for babies in the Asian and European or Other ethnic groups. For mothers 25 years of age or less, the rates for SUDI were significantly higher again. The SUDI rate for babies born in the most deprived areas (quintile 5, low socioeconomic areas and mul-tiple low social determinants of health) was significantly higher than the rate for all other deprivation quintiles (Ministry of Health 2020c).

As Figure 1.4 demonstrates, many of the leading causes of death during infancy continue to occur during the perinatal period. In 2015–17, 3 leading causes of infant deaths accounted for the majority (86%) of deaths: perinatal conditions (53%), congenital anomalies (23%), and symptoms, signs and abnormal fi ndings including sudden infant death syndrome (SIDS) (a subtype of SUDI) (9.3%).

Childhood Mortality In Australia, death rates for children older than 1 year of age have always been lower than those for infants. Children ages 5 to 14 years have the lowest rate of death. However, a sharp rise occurs during later adolescence, primarily from injuries, homicide and suicide. In 2017, 453 children aged 1–14 died—a rate of 10 per 100,000 children (12 per 100,000 for boys and 9.3 for girls). Boys accounted for 57% of child deaths (AIHW 2020). The death rate for children aged 1 to 4 years (15 per 100,000 children) was almost twice the rate for children aged 5 to 9 years (7.8) and 1.5 times as high as the rate for children aged 10 to 14 years (9.5). In 2015–17, the leading causes of child deaths were injuries (33%), cancer (19%) and diseases of the nervous system (10%)—rates of 3.5, 2.1 and 1.0 per 100,000 children, respectively. Children aged 1 to 4 years had the highest rates of death due to injury

for children (8.2%). It was also the most common disorder among boys (11%). Anxiety disorders were the second most common disor-ders among all children (6.9%), and the most common among girls (6.1%) (AIHW 2019).

New Zealand children aged 3 to 14 years showed anxiety related to peer problems to be the highest scoring mental health issue (13.7%) followed by conduct disorders (10.3%) (Ministry of Health 2018). Emotional symptoms were more prevalent in older age groups and boys experienced more conduct disorders than girls. For Māori chil-dren it was similar in reporting the same issues and problems but higher numbers in peer problems (17.8%) and conduct problems (16.7%), and again, higher in boys than girls (Ministry of Health 2018).

Infant Mortality The infant mortality rate is the number of deaths during the fi rst year of life per 1000 live births. It may be further divided into neonatal mortality (� 28 days of life) and post-neonatal mortality (28 days to 11 months). The infant death rate in Australia decreased from a peak of 5.7 deaths per 1000 babies in 1999 to 3.3 in 2017. The child death rate for children aged 1–14 halved between 1998 and 2017 (20 to 10 deaths per 100,000 children); however, since 2011, the death rate has stayed in the range of 10 to 12 deaths per 100,000 (AIHW 2020).

Between 2008 and 2017, the total number of births has decreased by 7%. In 2017 there were 390 fetal deaths and 284 infant deaths reg-istered. Infant death rates in 2017 for the Pacifi c and Māori peoples were the highest (8.7 and 5.9 per 1000 live births, respectively) com-pared to European or Other and Asian ethnic groups (3.4 and 3.7 per 1000 live births, respectively). This has been the pattern for the previ-ous 5 years (Ministry of Health 2020c).

In 2015–17, the leading causes of child (aged 1–14) deaths in Australia were injuries, cancer and diseases of the nervous system (AIHW 2019). Halving the gap between Australian Indigenous and

Fig 1.3 Leading causes of injury deaths among children aged 0–14, Australia, 2015–17. (Source: AIHW. (2019). Australia’s children: in brief. 17 December. AIHW, Canberra. https://www.aihw.gov.au/reports/children-youth/australias-children-in-brief/contents/table-of-contents . Data from: AIHW analysis of AIHW National Mortality Database.)

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7CHAPTER 1 Perspectives of Paediatric Nursing

Child and family health nursing is family centred, and assessments must include both the family and the individual’s data when planning care. The child’s community must also be considered when planning care. The community has the ability to infl uence the type of care and support that will be available for a child and the family.

Family-centred Care The philosophy of family-centred care recognises the family as the constant in a child’s life. Family-centred care is an approach to the planning, delivery and evaluation of healthcare that is grounded in mutually benefi cial partnerships among healthcare providers, patients and families (Institute for Patient- and Family-Centered Care 2014). Nurses support families in their natural caregiving and decision-making roles by building on their unique strengths and acknowledging their expertise in caring for their child both within and outside the hospital setting. The nurse considers the needs of all family members in relation to the care of the child.

Two basic concepts in family-centred care are enabling and empowerment. Professionals enable families by creating opportunities and means for all family members to display their current abilities and competencies and to acquire new ones to meet the needs of the child and family. Empowerment describes the interaction of professionals with families in such a way that families maintain or acquire a sense of control over their family’s lives and acknowledge positive changes that result from helping behaviours that foster their own strengths, abilities and actions.

Role of the Paediatric Nurse The paediatric nurse is responsible for promoting the health and wellbeing of the child and family. Nursing functions vary according to regional job structures, individual education and experience, and demography. Just as patients (children and their families) have unique

and diseases of the nervous system. Children aged 5 to 9 years had the highest rates of cancer (AIHW 2020).

THE ART OF PAEDIATRIC NURSING

Philosophy of Care Childhood is an important time for healthy development, learning and establishing the foundations for future wellbeing. Most Aus-tralian children are healthy, safe and doing well. However, child-hood is also a time of vulnerability and a child’s growth and devel-opment can vary depending on where they live and their family’s circumstances.

(AIHW 2019)

Health is infl uenced by social determinants such as individual and psychological make-up, lifestyle, environment, education, cultural infl uences, socioeconomic conditions and access to quality healthcare programs and services (WHO 2020). The WHO defi nes health as a multidimensional construct that incorporates physical, mental and social wellbeing and so is more than just the absence of disease or infi rmity (WHO 1946).

While the WHO’s defi nition of health is widely accepted, there can be variation across cultures. Aboriginal and Torres Strait Islander peoples take a broader perspective of health and view it not just as the physical wellbeing of the individual, but the social, emotional and cultural well-being of the whole community (AIHW 2020). The He Korowai Oranga aim is whānau ora, whereby Māori families support each other to achieve their full potential for health and wellbeing. Whānau (kuia, kor-oua, pakeke, rangatahi and tamariki) is identifi ed as the foundation of Māori society and is the central role in assisting families to reach their full potential for health and wellbeing (Ministry of Health 2002).

Fig 1.4 Leading causes of infant death, Australia, 2017. Note: Due to rounding the proportions do not sum to 100. (Source: Australian Institute of Health and Welfare (AIHW). (2020). Australia’s children. 3 April. AIHW, Canberra. https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/health-australias-children )

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8 SECTION I Children, Their Families and the Nurse

have meaningful relationships with children and their families and yet remain separate enough to distinguish their own feelings and needs. In a therapeutic relationship, caring, well-defi ned boundaries separate the nurse from the child and family. These boundaries are positive and professional and promote the family’s control over the child’s health-care. Both the nurse and the family are empowered and maintain open communication. In a non-therapeutic relationship, these boundaries are blurred, and many of the nurse’s actions may serve personal needs, such as a need to feel wanted and involved, rather than the family’s needs. Exploring whether relationships with patients are therapeutic or non-therapeutic helps nurses identify problem areas early in their interactions with children and families (see Nursing Care Guidelines box).

backgrounds, each nurse brings an individual set of variables that affect the nurse–patient relationship. No matter where paediatric nurses prac-tise, their primary concern is the welfare of the child and family.

There are many different roles for nurses specialising in the care of children and their families. For example, a paediatric nurse can pursue an advanced degree and become a clinical nurse specialist (CNS) in paediatrics, clinical nurse consult or nurse practitioner. CNSs are master-degree nurses who function in a variety of settings in both a direct and an indirect role. They model expert direct family-centred patient care. As our hospital settings change, so does the role of the paediatric nurse. The Australian Health Practitioner Regulation Agency (AHPRA) can provide further information on legislation, regulation and registration. In New Zealand, the National Framework for Nursing Professional Development and the Nursing Council of New Zealand provide information on legislation, regulation and registration.

Therapeutic Relationship The establishment of a therapeutic relationship is the essential founda-tion for providing high-quality nursing care. Paediatric nurses need to

NURSING CARE GUIDELINES

Exploring Your Relationships with Children and Families

To foster therapeutic relationships with children and families, you must fi rst become aware of your caregiving style, including how effectively you take care of yourself. The following questions should help you understand the therapeutic quality of your professional relationships.

Negative Actions

• Are you overinvolved with children and their families? • Do you work overtime to care for the family? • Do you spend off-duty time with children’s families, either in or out of the

hospital? • Do you call frequently (either the hospital or home) to see how the family is

doing? • Do you show favouritism towards certain patients? • Do you buy clothes, toys, food or other items for the child and family? • Do you compete with other staff members for the affection of certain patients

and families? • Do other staff members comment to you about your closeness to the family? • Do you attempt to infl uence families’ decisions rather than facilitate their

informed decision-making? • Are you underinvolved with children and families? • Do you restrict parent or visitor access to children, using excuses such as that

the unit is too busy? • Do you focus on the technical aspects of care and lose sight of the person

who is the patient? • Are you overinvolved with children and underinvolved with their parents? • Do you become critical when parents do not visit their children? • Do you compete with parents for their children’s affection?

Positive Actions

• Do you strive to empower families? • Do you explore families’ strengths and needs in an effort to increase family

involvement? • Have you developed teaching skills to instruct families rather than doing

everything for them? • Do you work with families to fi nd ways to decrease their dependence on

healthcare providers? • Can you separate families’ needs from your own needs?

• Do you strive to empower yourself? • Are you aware of your emotional responses to different people and situa-

tions? • Do you seek to understand how your own family experiences infl uence

reactions to patients and families, especially as they affect tendencies towards overinvolvement or underinvolvement?

• Do you have a calming infl uence, not one that will amplify emotional states? • Have you developed interpersonal skills in addition to technical skills? • Have you learned about ethnic and religious family patterns? • Do you communicate directly with persons with whom you are upset or take

issue? • Are you able to ‘step back’ and withdraw emotionally, if not physically, when

emotional overload occurs, yet remain committed? • Do you take care of yourself and your needs? • Do you periodically interview family members to determine their current

issues (e.g. feelings, attitudes, responses, wishes), communicate these fi nd-ings to peers and update records?

• Do you avoid relying on initial interview data, assumptions or gossip regard-ing families?

• Do you ask questions if families are not participating in care? • Do you assess families for feelings of anxiety, fear, intimidation, worry about

making a mistake, a perceived lack of competence to care for their child, or fear of healthcare professionals overstepping their boundaries into family territory, or vice versa?

• Do you explore these issues with family members and provide encouragement and support to enable families to help themselves?

• Do you keep communication channels open among yourself, family, medical practitioners and other care providers?

• Do you resolve confl icts and misunderstandings directly with those who are involved?

• Do you clarify information for families or seek the appropriate person to do so? • Do you recognise that from time to time a therapeutic relationship can change

to a social relationship or an intimate friendship? • Are you able to acknowledge the fact when it occurs and understand why it

happened? • Can you ensure that there is someone else who is more objective who can

take your place in the therapeutic relationship?

Family Advocacy and Caring Although nurses are responsible to themselves, the profession and the institution of employment, their primary responsibility is to the consumer of nursing services: the child and family. The nurse must work with family members, identify their goals and needs and plan

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9CHAPTER 1 Perspectives of Paediatric Nursing

decisions by assigning different weights to competing moral values. These competing moral values may include: autonomy, the patient’s right to be self-governing; non-malefi cence, the obligation to minimise or prevent harm; benefi cence, the obligation to promote the patient’s wellbeing; and justice, the concept of fairness. Nurses must determine the most benefi cial or least harmful action within the framework of societal mores, professional practice standards, the law, institutional rules, the family’s value system and religious traditions, and the nurse’s personal values.

Nurses must prepare themselves systematically for collaborative ethical decision-making. They can accomplish this through formal coursework, continuing education, contemporary literature and work to establish an environment conducive to ethical discourse.

The nurse also uses the professional code of ethics for guidance and as a means for professional self-regulation. Nurses may face ethical is-sues regarding patient care, such as the use of lifesaving measures for VLBW newborns or the terminally ill child’s right to refuse treatment.

CLINICAL REASONING AND THE PROCESS OF PROVIDING NURSING CARE TO CHILDREN AND FAMILIES

Clinical Reasoning A systematic thought process is essential to a profession. It assists the professional in meeting the patient’s needs. Clinical reasoning is a cognitive process that uses formal and informal thinking to gather and analyse patient data, evaluate the signifi cance of the information and consider alternative actions (Levett-Jones 2017). It is based on the scientifi c method of inquiry, which is also the basis for the nursing process. Clinical reasoning and the nursing process are considered crucial to professional nursing in that they constitute a holistic approach to problem-solving.

Clinical reasoning is a complex developmental process based on rational and deliberate thought. Clinical reasoning provides a com-mon denominator for knowledge that exemplifi es disciplined and self-directed thinking. The knowledge is acquired, assessed and organised by thinking through the clinical situation and developing an outcome focused on optimum patient care. Clinical reasoning transforms the way in which individuals view themselves, understand the world and make decisions. In recognition of the importance of this skill, Critical Thinking Exercises included in this text demonstrate the importance of clinical reasoning. These exercises present a nursing practice situa-tion that challenges the student to use the skills of clinical reasoning to come to the best conclusion. A series of questions leads the student to explore the evidence, assumptions underlying the problem, nursing priorities and support for nursing interventions that allow the nurse to make a rational and deliberate response. These exercises are designed to enhance nursing performance in clinical reasoning.

Nursing Process The nursing process is a method of problem identifi cation and prob-lem-solving that describes what the nurse actually does. The nursing process model includes assessment, diagnosis, outcomes identifi cation, planning, implementation and evaluation.

Assessment Assessment is a continuous process that operates at all phases of problem-solving and is the foundation for decision-making. Assessment involves multiple nursing skills and consists of the pur-poseful collection, classifi cation and analysis of data from a variety of sources. To provide an accurate and comprehensive assessment, the

interventions that best address the defi ned problems. As an advocate, the nurse assists the child and family in making informed choices and acting in the child’s best interest. Advocacy involves ensuring that families are aware of all available health services, adequately informed of treatments and procedures, involved in the child’s care and encour-aged to change or support existing healthcare practices.

As nurses care for children and families, they must demonstrate caring, compassion and empathy for others. Parents perceive caring as a sign of quality in nursing care, which is often focused on the non-technical needs of the child and family. Parents describe ‘personable’ care as actions by the nurse that include acknowledging the parent’s presence, listening, making the parent feel comfortable in the hospital environment, involving the parent and child in the nursing care, show-ing interest in and concern for their welfare, showing affection and sensitivity to the parent and child, communicating with them and individualising the nursing care. Parents perceive personable nursing care as being integral to establishing a positive relationship.

Disease Prevention and Health Promotion Every nurse involved in caring for children must understand the importance of disease prevention and health promotion. A nursing care plan must include a thorough assessment of all aspects of child growth and development, including nutrition, immunisations, safety, dental care, socialisation and education. If problems are identifi ed, the nurse implements a care plan and health promotion and/or refers the family to other healthcare providers or agencies.

Health Education Health education is inseparable from family advocacy and prevention. Health education may be the nurse’s direct goal, such as during parent-ing classes, or may be indirect, such as helping parents and children understand a diagnosis or medical treatment, encouraging children to ask questions about their bodies, referring families to health-related professional or lay groups, supplying patients with appropriate l iterature, and providing health promotion.

Health education is one area in which nurses often need prepara-tion and practice with competent role models because it involves transmitting information at the child’s and family’s level of under-standing and desire for information. As an effective educator, the nurse focuses on providing the appropriate health education with generous feedback and evaluation to promote learning.

Coordination and Collaboration The nurse, as a member of the healthcare team, collaborates and coor-dinates nursing care with the care activities of other professionals and works within a multidisciplinary team approach. A nurse working in isolation rarely serves the child’s best interests. The concept of holistic care can be realised through a unifi ed, interdisciplinary approach by being aware of individual contributions and limitations and collabo-rating with other specialists to provide high-quality health services. Failure to recognise limitations can be non-therapeutic at best and destructive at worst. For example, the nurse who feels competent in counselling but who is really inadequate in this area may not only prevent the child from dealing with a crisis but also impede future success with a qualifi ed professional. Nursing should be seen as a major contributor to ensuring that the healthcare team focuses on high-quality, safe care.

Ethical Decision-making Ethical dilemmas arise when competing moral considerations underlie various alternatives. Parents, nurses, medical practitioners and other healthcare team members may reach different but morally defensible

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10 SECTION I Children, Their Families and the Nurse

ensure that the outcomes are met and there is adequate care for resolving existing or potential health problems.

Documentation Documentation is essential for all parts of the clinical reasoning cycle. Evaluation is best performed with written evidence of progress towards outcomes.

Quality Outcome Measures National Health Strategies for Children A key objective of the National Healthcare Agreement from the Council of Australian Governments (COAG) is that Australians are born healthy and remain healthy. This is also the vision of the Healthy, Safe and Thriving : National Strategic Framework for Child and Youth Health (the framework). Even though a new National Federation Reform Council (NFRC) was announced, which is to replace the COAG meetings, the National Cabinet is to remain at the centre of the NFRC and the focus is to remain as above: that Australians are born healthy and remain healthy. At present the National Cabinet will focus specifi cally on responding to the COVID-19 pandemic.

The framework was endorsed by the Australian Health Ministers’ Advisory Council (AHMAC) in 2015 and provides a 10-year overarch-ing vision and set of priorities for child and youth health, on which other targeted health policies at the national and/or state and territory level can build. The framework’s priorities are to: • equip children and young people with the foundations for a healthy

life • support children and young people to become strong and resilient

adults • support children and young people to live in healthy and safe

homes, communities and environments • ensure children and young people have equitable access to health-

care services and equitable health outcomes • improve systems to optimise the health outcomes of children and

young people. Improvement of child health and wellbeing outcomes is also the

goal of the Australian Government’s National Action Plan for the Health of Children and Young People: 2020–2030 (the action plan).

This plan builds on the framework. It has these fi ve key priority areas: • improve health equity across populations • empower parents and caregivers to maximise healthy development • tackle mental health and risky behaviours • address chronic conditions and preventive health • strengthen the workforce.

Improving Child Wellbeing Making New Zealand the best place in the world to be a child is a top priority for the New Zealand Government. The health system is well-placed to contribute to achieving this, by providing services that keep children healthy and identifying and addressing issues at an early stage. This gives all children the foundation upon which to thrive socially, emotionally and developmentally.

Universal healthcare for children in New Zealand is delivered by the Well Child/Tamariki Ora program. This service is the main pro-vider of the government’s child wellbeing programs. The aim is to ensure that Well Child/Tamariki Ora is well resourced and achieves its outcomes. This program will be reviewed to strengthen Well Child/Tamariki Ora by: 1. improving sustainability and performance of the Well Child/

Tamariki Ora service

nurse must consider information about the patient’s biophysical, psychological, sociocultural and spiritual background.

Nursing Diagnosis The next stage of the nursing process is problem identifi cation and nursing diagnosis. At this point, the nurse must interpret and make decisions about the data gathered. Not all children have actual health problems; some have a potential health problem, which is a risk state that requires nursing intervention to prevent the development of an actual problem. Potential health problems may be indicated by risk factors, or signs that predispose a child and family to a dysfunctional health pattern and are limited to individuals at greater risk than the population as a whole. Nursing interventions are directed towards reducing risk factors. To differentiate actual from potential health problems, the word risk is included in the nursing diagnosis statement (e.g. Risk for Infection).

Outcomes Identifi cation The goal for outcomes identifi cation is to establish priorities and select expected patient outcomes or goals. The nurse organises information during assessment and diagnosis, and clusters these data into cate-gories to identify signifi cant areas and make one of the following decisions. • No dysfunctional health problems are evident; health promotion is

emphasised. • Risk for dysfunctional health problems exists; interventions are

needed for health promotion and illness prevention. • Actual dysfunctional health problems are evident; interventions are

needed for illness management, illness prevention and health promotion.

• Specifi c outcomes are formulated to address the realistic patient- and family-focused goals.

Planning After identifying specifi c patient- and family-focused goals, the nurse develops a care plan specifi c to the identifi ed outcomes. The outcome is the projected or expected change in a patient’s health status, clinical condition or behaviour that occurs after nursing interventions have been instituted. The care plan must be established before specifi c nursing interventions are developed and implemented.

Implementation The implementation phase begins when the nurse puts the selected intervention into action and accumulates feedback data regarding its effects (or the patient’s response to the intervention). The feed-back returns in the form of observation and communication and provides a database on which to evaluate the outcome of the nursing intervention. It is imperative that continual assessment of the patient’s status occurs throughout all phases of the nursing process, thus making the process a dynamic rather than a static problem-solving method.

Evaluation Evaluation is the last step in the nursing care process. The nurse gathers, sorts and analyses data to determine whether: (1) the estab-lished outcome has been met; (2) the nursing interventions were appropriate; (3) the plan requires modifi cation; or (4) other alterna-tives should be considered. The evaluation phase either completes the nursing process (outcome is met) or serves as the basis for selecting alternative interventions to solve the specifi c problem.

With the current focus on patient outcomes in healthcare, the patient’s care is evaluated not only at discharge but thereafter as well to

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11CHAPTER 1 Perspectives of Paediatric Nursing

2. driving equitable health and development outcomes for children 3. enabling Well Child/Tamariki Ora to more effectively contribute to

wider child wellbeing 4. ensuring value for money.

The main aim of the review is to assess how Well Child/Tamariki Ora can improve in meeting the needs of children, caregivers and wider communities and enable children to be empowered to thrive and achieve (Ministry of Health 2020a).

R E V I E W Q U E S T I O N S

1. The newest nurse on the paediatric unit is concerned about main-taining a professional distance in her relationship with a patient and the patient’s family. Which comment indicates that she needs more mentoring regarding her patient–nurse relationship?

A. ‘I realise that caring for the child means I can visit them on my days off if they ask me.’

B. ‘When the mother asks if I will care for her daughter every day, I explain that the assignments change based on the needs of the unit.’

C. ‘When the mother asks me questions about my family, I answer politely, but I offer only pertinent information.’

D. ‘I engage in multidisciplinary rounds and listen to the family’s concerns.’

2. A family you are caring for on the paediatric unit asks you about nutrition for their baby. What facts will you want to include in this nutritional information? Select all that apply.

A. Breastfeeding provides micronutrients and immunological properties.

B. Eating preferences and attitudes related to food are established by family infl uences and culture.

C. Most children establish lifelong eating habits by 18 months old. D. During adolescence, parental infl uence diminishes and

adolescents make food choices related to peer acceptability and sociability.

E. Because of the stress of returning to work, most mothers use this as a time to stop breastfeeding.

Correct Answers 1. A; 2. A, B, D

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12 SECTION I Children, Their Families and the Nurse

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