Musculo-skeletal system

This chapter aims to highlight the principles of orthopaedic nursing and the skills required to perform effective musculoskeletal care of orthopaedic injury in children. Musculo-skeletal injury is one of the most frequently encountered problems in children’s nursing. Almost 20% of children who present with injury have sustained a fracture (Hart et al., 2006). When children have fractures, they are generally brought to emergency departments. Whether the fractures are simple or complex, or they require surgical intervention or not, fractures produce a great deal of anxiety for children and their families. Children’s nurses are in an ideal situation to use their nursing knowledge to provide optimal care for children with musculo-skeletal injury. The initial assessment and immediate treatment of an injured extremity is fundamentally important in ensuring a good outcome. Delay in recognition of neurovascular compromise can lead to a condition known as compartment syndrome (CS). If ignored, a limb can become seriously compromised, which could eventually lead to amputation of the limb or even the death of the patient. However, having the foundation of knowledge regarding total neurovascular function can equip the nurse with accurate assessment skills and the knowledge of the need for immediate action. Neurovascular assessment used correctly provides the best patient care with the best possible outcome. Compartment syndrome is a possible complication for every patient with a fracture, sprain, or following orthopaedic surgery. Any deviation from the normal range of the neurovascular parameters should be highlighted immediately. Early identification of the symptoms will prompt immediate treatment and prevent any compromise of the limb. In addition the immature skeleton of children has unique properties that directly affect the management of fractures in children. By the end of this chapter you will be able to: ● Explain the nursing assessment you would undertake for an infant/child presenting with musculo-skeletal injury. ● Understand the principles of neurovascular assessment and complete all the aspects involved in assessing neurovascular status. ● Understand the rationale and purpose of the musculo-skeletal nursing skills outlined such as care of the child with a cast.

Introduction to clinical skills in children’s nursing

This book aims to provide nursing students with information about a broad range of clinical skills that they may use while nursing children. In recognition of the challenges in the healthcare setting, there is now greater emphasis on ensuring that nurses are prepared adequately to deliver safe and competent care, and that nurses are equipped with both the knowledge and practical skills to enable them to perform procedures safely and sensitively for children. This text aims to take account of these issues and serve as an essential resource for nurses and nursing students. Changing trends such as the move away from hospital care, shorter hospital stays, increased use of day surgery and outpatient care, parents undertaking procedures in the home supported by community care teams, and development of primary care services, present challenges to contemporary children’s nursing practice. Technological advances also mean that children now undergo more intensive technical procedures and complex treatment protocols, and the nurse has to be equipped with a diverse range of clinical skills. In this book we try to provide a comprehensive guide by addressing the following themes and challenges: In addition to the fundamental physical clinical skills that are required of a nurse, attention is also drawn to the important psychosocial aspects of skill delivery throughout this book. In particular skills of communication and family centred care are presented as overarching themes. This emphasis is consistent with changing trends in children’s nursing, whereby shorter hospital stays, and increased acuity of children, means that there is now less time to develop a relationship with the child and family, less time to build rapport and trust, which could ultimately impact negatively on the hospital experience for that family. Building relationships, developing trust, and family centred care are pivotal to the success of modern children’s nursing. In an attempt to negate the potential for adverse aspects of hospitalization, increasingly families are encouraged to remain with their child during their hospital stay. This presents a unique challenge for nursing students, who may find themselves daunted by the fact that they are caring for not one child, but both the child and family.

Integumentary system

The skin is an organ that serves many functions in maintaining homeostasis in the body (Bryant, 2000). A wide range of diseases manifest in changes in the skin and its appendages, and because the skin is visible and its disorders are often disfiguring, skin disorders can cause emotional and psychological stress for children and their families (Ball & Bindler, 2007). Skin diseases affect 20–33% of the population at any one time, seriously interfering with activities in 10% (Byrant, 2000). Epidemiological evidence suggests that many cases of skin disease do not reach the general practitioner (GP) or even the local pharmacist; nevertheless, each year about 15% of the population consult their GPs about skin complaints (Bryant, 2000). Skin disorders are among the most common health problems in children (Butcher & White, 2005). The infant and child are possibly more vulnerable to the effects of skin disorders and breakdown due to their underdeveloped integumentary system. Understanding the normal condition of the skin can help in the identification of abnormal signs and prompt treatment of skin disorders (Butcher & White, 2005). This chapter will focus on the integumentary system of the child, with reference to the normal structure of the skin together with common alterations and injuries to the skin of the child and the skills required for their nursing management. At the end of this chapter you should be able to do the following: ● Understand the normal child skin anatomy and physiology. ● Understand the fundamentals of a skin assessment in a child. ● Develop an awareness of the management of common skin alterations. ● Understand the nature and treatment of a child with a skin injury. The skin of an infant or child is normally fundamentally the same as that of an adult, although the blood and nerve supplies are immature and the dermis thinner, with less collagen and fewer elastic fibres. This means that the skin is fragile and can be more easily damaged through physical and mechanical trauma (Turnball, 2007). The skin of a newborn is found to have lanugo, which is a very fine, soft, and unpigmented coat of hairs covering its body until it is shed about 14 days after birth.

The endocrine system

This chapter aims to explore the nursing skills required to care for the child and family with an underlying endocrine disorder both in a healthcare setting and in the community. This chapter will include an overview of the anatomy and physiology of the endocrine system, related pharmacology and microbiology, and a detailed description of the main skills involved in caring for children with an endocrine disorder and their families. Endocrine disorders in childhood are generally of a chronic nature, therefore prompt, accurate treatment and management are essential to ensure normal development into fully functioning adulthood. Disorders of the endocrine system can manifest their effects immediately or in a more gradual manner over days to months. Endocrine disorders most commonly occur due to three main reasons: a disordered endocrine system, often as a result of a genetic abnormality; overproduction of a particular hormone; or underproduction of a particular hormone (Evans & Tippins, 2008). Type 1 diabetes mellitus accounts for approximately 50% of endocrine disorders in childhood with an incidence in children (0–14 years) of 13.5 per 100,000 in the UK (Raine et al., 2006). Although some general principles apply to the nursing care of children with an endocrine disorder, you will need to refer to local policy and be familiar with local protocols regarding the nursing management of these children and their families in the hospital and the community. It is anticipated that you will be able to do the following once you have read and studied this chapter: ● Understand the anatomy and physiology of the endocrine system and how it affects many of our bodily functions. ● Understand the predominant pathological conditions related to the endocrine system. ● Understand the key nursing skills required to care for a child with an endocrine disorder and their family. The endocrine system is a chemical communi cation system that consists of hormone producing cells, hormones, and receptors (Glasper & Richardson, 2006). This system regulates and controls the body’s metabolic processes including energy production, growth, fluid and electrolyte balance, responses to stress, and sexual reproduction (Baxter et al., 2004).

Gastrointestinal system

The aim of this chapter is to provide you with knowledge and understanding of the skills required in providing care to the child with a gastrointestinal disorder. This chapter will focus primarily on the most frequently encountered procedures both in the hospital and in the community setting. In addition, the importance of family centred care and a multicultural approach to care will be discussed. Some of the skills outlined in this chapter may be classified as advanced skills, for example, caring for a child on parenteral nutrition, and therefore you should seek appropriate guidance/ supervision when undertaking these practices. Moreover, it is essential that the student follows appropriate care plans, works within his/her scope of professional practice, and adheres to local policy in relation to carrying out nursing care (Nursing and Midwifery Council (NMC), 2007). This chapter will enable you to: ● Briefly describe the anatomy and physiology of the gastrointestinal system. ● Understand the procedures outlined in the chapter. ● Explain the rationale for the care you provide. ● Understand the importance of the holistic needs of the child when carrying out procedures. ● Understand the importance of family centred care and a multicultural approach to care. Knowledge of national and local policies and guidelines are recommended to enhance learning, e.g. National Institute of Health and Clinical Excellence (NICE) guidelines. Where reference is made to national guidelines, students are advised to refer to them for more detailed information. It is important that the student has a comprehensive knowledge of the anatomy and physiology of the gastrointestinal system to support understanding of many of the clinical skills described in this chapter. The following section will briefly outline the structure and function of the gastrointestinal tract. Knowledge of the changes that occur in the gastrointestinal tract as the child grows and develops is paramount to providing appropriate care and these will be signposted as they relate to skills throughout this chapter. For more detailed information refer to an anatomy and physiology textbook.

Neurological system

This chapter aims to give you knowledge and understanding of the skills required to provide safe and effective care to a child presenting with a neurological disorder. The chapter will focus mainly on the more frequently encountered neurological conditions and procedures both in a hospital and community setting. In addition the importance of family centred care (Chapter Two) and a culturally sensitive approach to care will be discussed. ● The rationale for undertaking a neurological assessment and how to carry out a neurological assessment on a child. ● The important elements of care of the child with a head injury based on the best practice. ● Key responsibilities of the nurse before, during, and after a lumbar puncture procedure. ● Various approaches to neurological imaging and the main principles involved in preparing a child for these. ● The main causes of seizures in childhood. ● The main principles involved in caring for a child with a convulsive seizure. ● The nurse’s role in caring for an unconscious child. Good knowledge of national and local polices and guidelines in relation to this area are recommended to compliment learning in this chapter. Furthermore it is essential for students to have a good understanding of the anatomy and physiology of the neurological system when caring for a child with a neurological disorder. A thorough understanding and knowledge of the key structures and functions of the brain will assist in understanding neurological conditions and will help in appreciating the significance and relevance of monitoring neurological status (this section will concentrate mainly on the structure and function of the brain). Nevertheless, it is advisable to revise in more depth the nervous system in your core anatomy and physiology book. Knowledge from other chapters is also advisable in order to understand the interdependence between body systems and the brain.

The respiratory system

The aim of this chapter is to provide an outline of the underpinning theory and relevant information needed to deliver safe and effective, family centred, evidence based care to the child or young person who presents with breathing difficulties. In is anticipated that at the end of this chapter you will be able to: ● Understand the anatomy and physiology of the respiratory system. ● Discuss the concept of visual assessment of breathing, including monitoring and recording of respiratory rate, oxygen saturation levels, and peak expiratory flow rates. ● Explain oxygen therapy and the use of airway adjuncts. ● Reflect upon methods and equipment used for suctioning. ● Discuss tracheostomy management, care of intrapleural drainage, and endotracheal tubes. ● Apply the concepts and principles outlined relevant to the hospital and community setting. This is the system through which oxygen is breathed in from the external environment, either by the nose or mouth, and a waste product (carbon dioxide) is excreted. The respiratory system consists of respiratory passages, which carry air via the nose to the lungs, and a network of blood capillaries in the lungs. The respiratory passages include the nose, pharynx, larynx (voice box), trachea, two bronchi (one bronchus to each lung), and copious bronchial tubes, which divide and lead to millions of alveoli (tiny air sacs). There are two lungs either side of the heart in the thoracic cavity. They are made up of bronchial tubes, alveoli, blood vessels, and nerves (McCance & Heuther, 2006). Air containing oxygen (O2) and carbon dioxide (CO2) is breathed into the lungs. This fills the alveoli. It is separated from the blood in capillaries by two semi-permeable membranes. These make up the walls of the alveoli and capillaries. Oxygen is at a higher concentration in the alveoli. It therefore passes from the alveoli into the blood. Carbon dioxide is higher in concentration in the blood, so it passes from the blood into the alveoli. Oxygen is carried in the blood in haemoglobin (red blood corpuscles). Breathing is the regular inflation and deflation of the lungs, maintaining a steady concentration of atmospheric gases in the alveoli (MacGregor, 2000).

Drug administration

By the end of this chapter you will be introduced to the concepts of pharmacokinetics and pharmacodynamics with specific emphasis on the infant, child, and young person. You will be presented with the current evidenced- based practice in relation to differing routes of drug administration in children and young people, underpinned by a firm rationale throughout. The key points to consider when administering medications via differing routes to children will be explored. Throughout this chapter the importance and method of drug calculations and mental mathematics will be highlighted, as befits their importance in the safe preparation and administration of all medications. It is anticipated that you will be able to do the following once you have read and studied this chapter: ● Discuss pharmacokinetics and pharmacodynamics as they relate to drug administration with children. ● Understand the mathematical calculations required to accurately prepare and administer medications in children. ● Understand the key nursing skills required to administer medications to children and young people via differing routes. Historically, drug development specifically for children was only conducted for common disorders/diseases where medication was part of the accepted treatment. Examples are medicines for epilepsy or asthma, antibiotics, or vaccines (Rose, 2005). Because the numbers of children are small in comparison with adults, and the child population is subdivided into age groups from neonates to teenagers, pharmaceutical companies are governed by the commercial market. Consequently they assign limited resources to drug development in the child population because of more limited profit margins. However, this situation is changing, as the European Union established a European Network for Drug Investigation in Children in 1998, with a commitment to improve both clinical use and research into drugs for children (Van den Anker & Choonara, 1999). An international meta-register of controlled clinical trials has been created where particular emphasis is placed on paediatric aspects (Bonati et al., 2001). All of these initiatives serve to change the prevailing view of children as ‘therapeutic orphans’ to an acknowledgement that children are consumers of healthcare services and as such have the right both ethically and morally to medications that are designed and trialled for them specifically.

Essential care

This chapter examines the principal skills of assessment and management of pain and wounds. It provides information on the assessment of a child’s skin and the management of eye and ear care, skin care, and mouth care. It also provides information on mobility and the moving and handling care of children. The care discussed is applicable to a variety of nursing settings such as the hospital or in the community and family participation and cultural needs are incorporated in keeping with the philosophy of family centred care (Chapter Two). It is anticipated that you will be able to do the following after you have read and studied this chapter: ● Discuss the importance of pain assessment to the child’s overall pain management. ● Understand different pain relief medications used to manage pain in children. ● Identify the factors affecting wound healing and discuss assessment of a wound. ● Develop an awareness of the importance of cleaning eyes and ears in children. ● Understand the general principles of maintaining mouth care in the child. ● Appreciate differences in the child’s care and needs at different developmental stages. ● Be aware of general principles of maintaining skin care for the child, including: relating anatomy and physiology of skin to skin care; carrying out an assessment of child and skin; and ensuring child safety and dignity. ● Develop a greater understanding of parent participation and cultural needs of the child in skin care. ● Understand the principles of moving and handling, describing the carrying and supporting of infants and children. You can review your knowledge in some of these areas using the online resource feature that accompanies this book. Pain assessment is an essential first step in the relief of pain. It forms a major part of overall pain management and provides a foundation on which future care is based. Prior to considering pain assessment for the child you should be familiar with the related anatomy and physiology of the child’s condition, an outline of which you should find in a chapter of this book. Revision of your core textbook in anatomy and physiology would also be useful.

Consent and legal/ethical matters

This chapter will explore contemporary child protection issues including safeguarding policies and laws currently in place for children, in order to provide a framework to guide your understanding and practice as a nursing student. We will also highlight the influence of other agencies in fulfilling their statutory responsibility for safeguarding children and the importance of inter-professional work. It is important that student nurses can recognize the presentation of children who may have suffered abuse and so common scenarios are explored and discussed. Examples of the nature and range of abuse will be outlined as will the skills used for both recognition and identification. You may find some of the content disturbing, and it may be useful for you to seek support and guidance when reading the chapter. The chapter commences with a discussion of the background literature in this area, which provides a definition and explanation of abuse and outlines related contributory factors. In order to provide a discussion of the legislation related to this topic, examples from the United Kingdom (UK) will be outlined. Legislation in this area varies between countries; therefore it is not possible to provide information on the scope of the law in individual countries. It may be useful to refer to your own country’s legislation when considering the chapter content. By reading this chapter and engaging with the various activities, you will have: ● A basic understanding of several aspects of child protection and safeguarding policy and law (examples are drawn from the UK and Ireland). ● An understanding of the nature of presenting abuse in children. ● An understanding of child protection/safeguarding guidelines that would enable you to act if you have concerns. ● An awareness of accountability and responsibility issues in relation to your role in nursing children. From preceding chapters you will have developed an understanding that children need to grow up in a nurturing environment that encourages their physical and emotional development.