Consultants and Advisers

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1 Care of the Child

2 Editorial Board Chairman Sheila Collins, OBE, BA(Hons), RGN, RSCN, RNT, FRCN is an Associate Lecturer to the postgraduate certificate course in the education of adults at The University of Surrey, Guildford. She was formerly the Director of Nursing Education at The Princess Alexandra School of Nursing, The London Hospital, a member of the Committee on Nursing ( ) under the Chairmanship of Professor (now Lord) Asa Briggs, and a member of the Advisory Committee on Training in Nursing of the European Commission. She was a member of the English National Board and a member of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting from She has travelled widely in Europe, Australia, New Zealand, the United States and Canada, not only to study and to lecture, but also to represent the Royal College of Nursing (of which she was twice Deputy President) and to assist in the work of the International Council of Nurses. Series Editors Patricia-Hunt, RGN, RSCN, SCM, RNT, Dip Adv Ed is Director of Nurse Education at West Berkshire School of Nursing and was previously Senior Tutor at Bristol and Weston School of Nursing. She is an external examiner for London University, Diploma in Nursing and member of the Course Planning Team for the CNNA Diploma/Degree in Nursing at Buckinghamshire College of Higher Education. She is a member of Advisory Committees at Buckinghamshire College of Higher Education and Bracknell College of Further Education. She is involved in the early stages of establishing links between West Berkshire School of Nursing and Bulmershe College of Higher Education, Reading. Other interests include membership of the distance learning Open Tee Steering Committee for Continuing Nurse Education with Barnet and Manchester Colleges with the Manpower Services Commission. Bernice Sendell, BA(Hons), RGN, SCM, RNT is Assistant Director of Nurse Education at the Bristol and Weston School of Nursing. She is a member of the course liaison/management groups for the BA(Hons) Degree in Nursing and for the Diploma in Nursing, and a member of the Advisory Committee for the CertEd(FE), all at Bristol Polytechnic. Other interests include membership of the Editorial Advisory Group for a professional journal and steering committee membership for two distance learning projects (at the Distance Learning Centre, South Bank Polytechnic, and the Continuing Nurse Education Open Tee at Barnet and Manchester Colleges with the Manpower Services Commission). Gill Garrett, BA, RGN, RCNT, DipN(Lond), CertEd(FE), RNT, FPCert was previously Nurse Tutor at the Bristol and Weston School of Nursing. She is a freelance writer and lecturer in health and community studies, and a Member of the RCN Working Party Improving Care of the Elderly in Hospital. Helen Lewer, BSc(Hons), RGN, RSCN, RNT is a Tutor at the Nightingale School of Nursing, St Thomas's Hospital, London. In 1980 she was awarded a scholarship through the Florence Nightingale Memorial Committee to study paediatric nurse training in the USA and Canada. Hazel Ball, RGN, SCM, MTD is Director of Nursing Services, Midwifery and Paediatrics, Nottingham Health Authority (Teaching), and was previously Divisional Nursing Officer (Midwifery and Gynaecology) in central Derbyshire. She is a member of the Association of Supervisors of Midwives and was a member of the General Nursing Council. Alan Parrish, RGN, RNMH is past Director of Nursing Services at StLawrence's Hospital, Caterham, Surrey. He is now Nurse Adviser to the Society of Mental Handicap Nursing at the Royal College of Nursing for the United Kingdom. Consultants and Advisers Anne Betts, BSc(Hons), RGN, RNT is a course tutor and lecturer in biological sciences at the Institute of Advanced Nursing Education, The Royal College of Nursing. She is an editorial board member of Good Health. Marigold Potter, BA, RGN, DipN, Dip NEd, RNT is a specialist Tutor for care of the elderly at The Princess Alexandra School of Nursing at The London Hospital, London. June Jolly, RGN, RSCN is Nurse Adviser with the Lisa Sainsbury Foundation. She is an Honorary member of NA WCH (The National Association for the Welfare of Children in Hospital) and author of The Other Side of Paediatrics: the everyday care of sick children, published by Macmillan in Ann Stewart, BA, RGN, SCM, MCD was, until June 1983, Educational Supervisor at the Central Midwives Board, and is a Member of the Council of the Royal College of Midwives. She is now Professional Officer for Midwifery Education Training and Practice at The English National Board for Nursing, Midwifery and Health Visiting. Janet Nevitt, RSCN, RGN, RCNT, RNTwas, until June 1986, a Tutor at The Princess Alexandra School of Nursing at The London Hospital. Geoff Bourne, RMN, RGN, RNT is an Education Officer at The English National Board for Nursing, Midwifery and Health Visiting and was previously Senior Tutor at The Princess Alexandra School of Nursing, at The London Hospital, London. The Contributor Daphne Hill, RNMS, RGN, RCNT, RNT has written the section discussing Susan, a baby with Down's Syndrome. She is Senior Nurse Tutor at the School of Nursing at St Lawrence's Hospital, Caterham, and has previously held nursing posts at the Fountain Hospital, London and St Heller Hospital and Queen Mary's Hospital for Children, Carshalton.

3 Care of the Child Helen Lewer Leslie Robertson SECOND EDITION MACMILLAN

4 Helen Lewer and Leslie Robertson 1987 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 7 Ridgmount Street, London WC1E7AE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. First published 1987 Published by MACMILLAN EDUCATION LTD Houndmills, Basingstoke, Hampshire RG21 2XS and London Companies and representatives throughout the world ISBN ISBN (ebook) DOI /

5 Contents Foreword to the series viii Preface to the second edition ix Acknowledgements xi A note on the series style xi Part 1 The Developing Child 1 Introduction 3 2 The infant (birth-1 year) 5 Physical characteristics 5 Explanation of the differing anatomical and physiological features 6 First measurements and observations 7 Emotional development 8 Development of social skills 9 Motor development 9 Development of play skills 12 Safety 12 Infant feeding 12 Elimination and changes in stools 15 3 The toddler ( years) 16 Physical characteristics 16 Motor development 17 Play 18 Safety 18 Psychological development 19 Development of social skills 20 Typical toddler day 21 4 The pre-school child ( years) 23 Physical characteristics 23 Motor development, play and safety 24 Psychological development 25 Development of social skills and intellectual ability 26 5 The school child ( years to 1 o-11 years) 28 Physical characteristics 28 Nutrition 29 Motor and cognitive development 30 Play and safety 33 Psycho-social development 33 6 The adolescent (11-18 years) 37 Introduction: some views on adolescence, past and present 37 Puberty 38 Nutrition 39 Mental growth and education 40 Psycho-social development 41 Fact Sheet 1: Jean Piaget's stages of cognitive development 45 Fact Sheet 2: Five stages of development: a comparison 46

6 7 Ensuring healthy development Care of mother and baby Medical examinations and assessments 8 When there is failure of care Accidents Child abuse Identification of illness and defects 9 The ill child at home Primary health care team Common symptoms and how they develop 10 Why children come into hospital Children admitted with infections Children admitted as a result of trauma/poisoning Planned admissions Emergency admissions Social admissions The child with malignancy Children with congenital abnormalities Developmental problems Part 2 Principles of Nursing Sick Children 11 Preparing the child for hospital How parents can prepare their child The child's view of hospital How hospital may affect the child 12 Why nursing children is different Limitations in understanding Emotional immaturity Developmental needs Working with the family Families from other countries 13 Creating the right environment Where children are nursed Communication Safety Play Education Theory into practice Part 3 The Sick Child 14 Nursing the acutely ill child and the child admitted for surgery 83 Acute illness 83 The planned admission 83 The child admitted in an emergency 86 Day surgery 86 Observation and investigations 87 Replacement therapy 90 Fluid administration 90 Infant feeding 91 vi

7 Elimination 92 Child hygiene 93 Administration of medicines 94 Preparation for surgery 96 Discharge from hospital 96 Nursing care plans for the child who is acutely ill 97 Nursing care plan for the child undergoing a planned adenotonsillectomy using an activities of living model 98 Nursing care plan for the child undergoing an emergency appendicectomy for a non-perforated appendix 109 Nursing care plan for the toddler undergoing day surgery for circumcision 116 Nursing care plan for the infant with gastro-enteritis using a self-care model 122 Fact Sheet 3: Principles of isolation nursing 129 Formulation of a care plan for the child with a head injury Living with a long-term illness 135 Long-term disease/disorder 135 The diagnosis, causation apd parental acceptance 135 Children's attitudes and ways of coping with long-term disorders 136 Recreation and education 137 The family 137 Support available 138 Hospital admission, assessment and nursing care 138 Nursing care plans for the child with a long-term illness 139 The pre-school child with cystic fibrosis 140 The adolescent with diabetes mellitus Nursing the child who is terminally ill 156 Terminal illness: definition, causes and acceptance 156 Principles of caring for the terminally ill child 157 Causes of death 158 Accepting the news that the child will die or has died 159 Attitudes to death 159 The child who dies in hospital 160 The child who dies at home 160 Bereavement 161 Nursing care plan for the terminally ill child The handicapped child 168 What is a handicap? 168 Living with a handicap: effects on child and family 169 Support, facilities and care 170 Nursing care plans/histories for the handicapped child 172 Nursing care plan/history for the adolescent with a multiple physical handicap 172 Nursing care plan/history for the school child with a sensory handicap 184 Nursing care plan for the baby with a mental handicap (by Daphne Hill) 190 Evaluation of progress for the baby/child with Down's Syndrome (by Daphne Hill) 196 Names and head office addresses of relevant societies and organisations 201 Index 203 vii

8 Foreword to the series This series of textbooks offers a fresh approach to the study of nursing. The aim is to give those beginning a career in nursing, and those already qualified, opportunities for reflection to broaden their approach to nursing education and to identity their own nursing values. The text includes material currently required by those preparing for qualification as a nurse and offers a basis for developing knowledge by individual studies. It should also assist qualified nurses returning to nursing, and those wishing to gain further insight into the nursing curriculum. The authors of each book in the series are from widely differing nursing backgrounds, and, as experienced teachers of nursing or midwifery, they are all well aware of the difficulties faced by nursing students searching for meaning from a mass of factual information. The nurse has to practise in the real world, and in reality nursing students need to learn to practise with confidence and understanding. The authors have therefore collaborated to illustrate this new perspective by making full use of individual nursing care plans to present the knowledge required by the nursing student in the most appropriate and relevant way. These textbooks can therefore be used in a wide variety of nursing programmes. The practice of nursing - as a profession and as a career - and the education of the nurse to fulfil her role are both affected by national and international trends. The Nurses, Midwives and Health Visitors Act 1979 in the United Kingdom, the Treaty of Rome and the European Community Nursing Directives 1977, as well as the deliberations and publications of the International Council of Nurses and the World Health Organization, all make an impact upon the preparation and the practice of the nurse throughout the world. Nursing values may not have changed over the past hundred years, but society and the patterns of both life and care have changed, and are constantly changing. It is particularly important, therefore, to restate the essentials of nursing in the light of current practice and future trends. Throughout this series the focus is on nursing and on the individual - the person requiring care and the person giving care - and emphasises the need for continuity between home and hospital care. Neighbourhood Nursing - A Focus for Care, the Report of the Community Nursing Review under the chairmanship of Julia Cumberlege (HMSO, 1986), has drawn attention to this need. The developing role of the nurse in primary care and in health education is reflected throughout this series. The authors place their emphasis on the whole person, and nursing care studies and care plans are used to promote understanding of the clinical, social, psychological and spiritual aspects of care for the individual. Each book introduces the various aspects of the curriculum for general nursing: the special needs of (1) those requiring acute care; (2) the elderly; (3) children; ( 4) the mentally ill; and (5) the mentally handicapped. The last category is a new text book in the Essentials of Nursing Series and is edited by a well-known and respected nurse for the mentally handicapped, with the help of contributors who are experienced in differing aspects of caring for people with mental handicap. The text on maternity and neonatal care, written by a midwifery teacher, provides the required material for nursing students and would be helpful to those undertaking preparation for further health visiting education. The authors wish to acknowledge their gratitude for the assistance they have received from members of the Editorial Board and from all those, too numerous to mention by name, who have contributed to their work: patients and their relatives, students, qualified nurses and colleagues. To all those nurse teachers who have read some of the texts, offering constructive criticism and comment from their special knowledge, we offer our grateful thanks. Lastly, we thank Elizabeth Home for her contribution to the physiology material in the text, and Mary Waltham for her help with this second edition Sheila Collins viii

9 Preface to the second edition Experience in a children's ward or department may be your first introduction to children sick or well. Some of you may have grown up with brothers, sisters and cousins while others may have baby-sat, run a Sunday School class or looked after younger children at school. All of you will have observed children in the streets, in playgrounds and in shops. Although you may not realise it, all these experiences can contribute to your understanding of children. Paediatric nursing is often approached with more than a little apprehension. This is understandable as children cannot always express their problems verbally and usually need their family around them. Many of your skills will be enhanced, particularly those of communication and observation. Paediatric nursing involves the whole family and you may find that it takes time to establish your role within this setting. Children are different! This fact is insufficiently appreciated both in society and within the nursing profession. Children are not 'mini-adults'. They are often refreshingly honest, accepting factual information readily, and they can be a joy to work with. The Nurses, Midwives and Health Visitors Approval Order 1983, Section 18, states that: '... courses leading to a qualification, the successful completion of which shall enable an application to be made to the parts of the Register, shall provide opportunities to enable the student to accept responsibility for her personal professional development and to acquire the competencies required.' Courses leading to entry to the general parts of the Professional Register include the study of the care of the child and his family, so providing an insight into the skills which would be required to nurse children. All the competencies are highlighted in this book and those of you undertaking a course for entry to the Sick Children's Nursing part of the Professional Register will also find this book useful. References for further reading are included, together with suggested exercises to aid self-directed learning. Use this book discerningly: you will not necessarily meet examples of all the nursing care plans. Hopefully it will guide you in your approach to children in making (and breaking!) relationships with them and their families and in caring for children who have varying needs. You may well be familiar with the 'Nursing Process'. The problem-solving/ reasoning approach is most suitable for use with children. The principles are discussed here. The assessment, planning, implementation and evaluation of nursing care is a logical process whereby the order of priorities of care are adjusted according to the patient's requirements. The 'process of nursing' is based on philosophy and should be a dynamic concept and not a paper exercise. There are a variety of approaches, ranging from the more generalised problemsolving approach to the more explicit use of specific nursing models/conceptual frameworks, e.g. Roper, Logan and Tierney, and Orem. This edition has been updated to include care plans based on each of these frameworks. They should not be used as rigid examples on which to plan care for your patients, but as an aid to developing your thought processes. Use the knowledge you have already gained about the process of nursing and various models of care, together with the information given both in this book (including other aspects of child care, e.g. child development) and in other books in the Essentials of Nursing Series, in order to plan for the very individual needs of children and their families. The philosophy of child care is influenced by the environment in which children grow up. The effects include cultural and sociological factors such as altered family dynamics, unemployment, and drug and alcohol abuse. Technological advances - computers, microchips, the Space Age - and advances in medical care, surgery and drugs, all have implications for the nurse in planning care and decision making. Children, wherever possible, should be cared for at home. Two reports ix

10 discuss the provision of care in the community: Fit for the Future, Committee on Child Health Services (Chairman S.D. M. Court) 1976; and Neighbourhood Nursing - A focus for care, Report of the Community Nursing Review (Chairman J. Cumberlege), What of the future? The nursing profession has become increasingly aware of the constraints of the present nurse education system and the need to plan for the provision of care and nursing practices appropriate for future needs. Important reports have recently been published by the professional and statutory bodies: The Education of Nurses: A New Dispensation. Commission on Nursing Education, Royal College of Nursing of the United Kingdom, Professional Education/Training Courses, English National Board, Project 2000: A New Preparation for Practice, United Kingdom Central Council, They are essential reading for all nurses as they make recommendations for the future of the nursing profession (including paediatric nursing) and they may well affect you! Paediatric nursing is challenging and rewarding. We hope you will enjoy it H.L. L.R. X

11 Acknowledgements The authors would like to thank Miss S. Collins, OBE, BA(Hons), RGN, RSCN, RNT, FRCN for her guidance and advice during the preparation of this book, and Miss S. Burr, RSCN, RGN, RNT for her helpful comments on the manuscript. They also wish to acknowledge the help of Mrs Deborah Fisher, BA, ALA who helped with the references, Mrs Patricia White who typed the manuscript and Mrs Jennifer Claridge, BSc (Hons), ARCS who made a number of helpful suggestions for improvement to both the text and to its presentation. The authors and publishers wish to thank Mrs Laura Huxley, Chatto and Wind us Ltd and Harper & Row, Publishers Inc for permission to reproduce an extract from 'Fifth Philosopher's Song' by Aldous Huxley in The Collected Poetry of Aldous Huxley, edited by Donald Watt. They also wish to acknowledge, with thanks, the following illustration sources: J. Allan Cash: pages 43, 54 (2 photographs), 87; Central Office of Information/Department of Health and Social Security (Crown Copyright): page 50; Susanne Szasz, Camera Press: page 16; John Topham Ltd: page 16; Sheelah Latham: pages 35, 68; Jim Brownbill: page 84; Colin Davey, Camera Press: pages 47, 49, 184; John Walmsley: pages 29, 35, 36; Nursing Times: pages 36, 50,57, 91, 192; The Guardian: page 36; R & S Greenhill: pages 36 and 43; Adrian Mott: pages 65, 73 (3 photographs), 85, 89, 90, 140; Alan Thomas: page 50. In the preparation of the second edition the authors are grateful to Mrs Deborah Fisher, BA, ALA for updating the references and to Mrs Betty Parramore for typing the manuscript. A note on the series style Throughout this book, in keeping with the other titles in this series, the term nursing student has been used to mean both student or pupil nurses and trained nurses who are undertaking post-basic training or who are keeping up to date with the recent literature. For clarity and consistency throughout the series the nurse is described as she; this is done without prejudice to men who are nurses or nursing students. Similarly, the patient is sometimes referred to as he, when the gender is not specifically mentioned. Care plans, which are used throughout the books in this series, are indicated by a coloured corner flash to distinguish them from the rest of the text. xi

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