Table Of Content

Contents Contributors vii eczema (including cradle 12.3 Acute gastroenteritis cap) 73 (vomiting and diarrhoea) Preface ix 9.11 Nappy rash 75 144 9.1 2 Pediculosis humanus capitus 12.4 Jaundice 148 Part I Clinical Issues in (head lice) 77 12.5 Threadworms 153 Paediatrics 1 9.13 Psoriasis 79 12.6 Diabetes mellitus 154 9.14 Scabies 83 12.7 Delayed sexual 1. A developmental approach to the 9.15 Viral skin infections (warts development (delayed history and physical examination in and molluscua puberty) 158 paediatrics 3 contagiosum) 85 12.8 Premature sexual development (precocious 2. Anatomical and physiological 10. Problems related to the head, puberty) 162 differences in paediatrics 8 eyes, ears, nose, throat or 12.9 Short stature 164 3. Care of the adolescent 12 mouth 88 12.10 Ingestions and poisonings 10.1 Congenital blocked 168 4. General principles in the nasolacrimal duct 88 13. Musculoskeletal problems, assessment and management of 10.2 Eye trauma 90 neurological problems and the ill child 15 10.3 The'red eye' 95 trauma 172 10.4 Common oral lesions 13.1 Limp and hip pain 172 5. Pharmacology in paediatrics 1 8 100 13.2 Lacerations 175 10.5 Common oral trauma 6. Internet resources for the nurse 1 3.3 Pain assessment and 105 practitioner 22 management 177 10.6 Acute otitis media 109 13.4 Febrile seizures 183 7. Paediatric telephone advice and 10.7 Amblyopia and strabismus 13.5 Head injury 185 management for the nurse 112 14. Genitourinary problems and practitioner 27 sexual health 1 89 11. Respiratory and cardiovascular 8. Transcultural nursing care 31 problems 1 16 14.1 Urinary tract infection 189 11.1 Asthma and wheezing 14.2 Enuresis 192 Part II Common Paediatric 116 14.3 Vulvovaginitis in the Problems 35 1 1.2 Bronchiolitis 121 prepubescent child 195 11.3 Pneumonia 124 14.4 Adolescent contraception 9. Dermatological problems 37 1 1.4 Stridor and croup 198 9.1 'My child has a rash' 37 (laryngotracheobronchitis) 14.5 Sexually transmitted 9.2 Acne 42 127 infections 202 9.3 Atopic eczema 47 11.5 Syncope 130 14.6 Painful male genitalia 9.4 Birthmarks 50 11.6 Chest pain 133 207 9.5 Burns 55 9.6 Cellulitis 59 12. Gastrointestinal and endocrine 15. Infectious diseases and 9.7 Food allergy 61 problems 137 haematology 21 3 9.8 Fungal skin infections 64 12.1 Acute abdominal pain 15.1 Acute fever (<7 days 9.9 Impetigo 70 137 duration) 213 9.10 Infantile seborrhoeic 12.2 Childhood constipation 15.2 Glandular fever (Epstein- dermatitis (ISD) or infantile and encopresis 141 Barr infection) 217 Contributors Editor Medical Consultant King's College Hospital Katie Barnes MSc MPH BSc(Hons) CPNP Peter Wilson MBCKB, MRCPCH NHS Trust, London Katie Barnes is a Certified Paediatric Peter received his medical degree in 14.4 Adolescent contraception Nurse Practitioner (CPNP) who emigrated 1993 from the University of Cape Town, Katie Barnes MSc MPH BSc(Hons) CPNP from America in 1997. Originally from South Africa. After working in primary Consultant, National Nursing Cape Cod, she received her undergraduate care paediatrics for 2 years he arrived in Leadership Programme, Manchester; nurse training in Boston at Northeastern the UK where he has worked in Certified Paediatric Nurse Practitioner, University in 1986 and subsequently paediatrics ever since. He became Old Swan NHS Walk-in Centre, Liverpool; Visiting Lecturer, moved to New York City where she a member of the Royal College of Paediatric Nurse Practitioner completed a Master of Science degree in Paediatrics and Child Health in 1997 Programme, City University, Paediatric Primary Care at Columbia and is currently in his final year as Saint Bartholomew School of Nursing University in 1989. After achieving her a Specialist Registrar in paediatric and and Midwifery, London; National Board Certification as a PNP, cardiac intensive care at Great Ormond Guest Lecturer, Paediatric Nurse she was named as a Fellow in the National Street Hospital. His special interests are Practitioner Programme, Saint Martin's Association of Paediatric Nurse sepsis and the critically ill child. College, Lancaster Practitioners and began working with 1. A developmental approach to the disenfranchised children on mobile Pharmacy Consultant history and physical Sara HigginSOn BPharm, MRPharmS medical units in the New York homeless 2. Anatomical and physiological and foster care systems. Katie followed Sara qualified as a pharmacist from differences in paediatrics this with a PNP position in paediatric Bradford University in 1992 and 3. Care of the adolescent haematology at Columbia-Presbyterian subsequently accepted a post at Ipswich 4. General principles in the assessment Medical Centre until she travelled to the Hospital in Suffolk. In 1994 she received and management of the ill child jungles of Guatemala to work with Mayan her London Diploma in Pharmacy 5. Pharmacology in paediatrics children in rural villages. She returned Practice from the London School of 12.1 Acute abdominal pain from Central America to conduct a Pharmacy. Sara chose to pursue paediatric 15.1 Acute fever community-based, randomised controlled and neonatal pharmacy in 1997. Kelly A Barnes DMD trial for the New York City Department Certificate of Advanced Graduate Study of Health and Columbia University Contributors in Endodontics, Boston University School School of Public Health where she also Andrea G Abbott DBO(T) BSc(Hons) SRO of Dental Medicine, Boston, USA. Private Practice, Endodontic Associates completed a Master of Public Health in Clinical Tutor/Orthoptist, of Lexington, USA 1996. Upon arriving in England, she Maidstone Ophthalmic Hospital, 10.4 Common oral lesions worked as a lecturer in child health and a Maidstone 10.5 Common oral trauma paediatric nurse practitioner (PNP) until 10.7 Amplyopia and strabismus Breidge Boyle MSc BSc RGN RSCN she moved to Liverpool in 2002 (where Dolsie Allen MSc RN CFNP Advanced Nurse Practitioner she continues her practice and consulting Former Senior Lecturer, (Neonatal), Great Ormond Street work). During her 6 years in England, Nurse Practitioner Programme, Hospital, London Katie has been very fortunate to Saint Martin's College, Lancaster Appendix 2 Age-appropriate B/P and collaborate in the education, training 14.3 Vulvo-vaginitis in the vital signs and policy development of advanced prepubescent girls Gill Brook CBE RSCN RGN paediatric nursing practice; she lectures, 14.5 Sexually transmitted infections Clinial Nurse Specialist, Liver Disease, consults and presents widely on a variety Gilly Andrews RGN ENBAOS ENBSIOS Birmingham Children's Hospital NHS of educational, clinical and advanced Clinical Nurse Specialist in Trust, Birmingham practice policy issues. Family Planning, 12.4 Jaundice VII Preface The academic preparation and role paediatric nurse practitioners (PNPs) as 'Paediatric Pearls' (i.e. important points development of the nurse practitioner in the standard of advanced nursing care for garnered from years of clinical practice) the UK has largely focused on adult infants, children and adolescents, NPs and a comprehensive bibliography. patients. This is in contrast to the clinical currently in the clinical front line are Appendices 1-3 include reference setting where the percentage of likely to benefit from a paediatric clinical material, largely pertaining to childhood paediatric consultations in busy reference text. It is from this rationale growth and development, such as age ambulatory sites (e.g. primary care, that Paediatrics: A Clinical Guide for appropriate vital signs and child growth accident and emergency, walk-in centres, Nurse Practitioners was derived. charts. Appendix 4 lists numerous child etc.) may approach 30-40%. A large Part One (Clinical Issues in Paediatrics) protection resources for the NP. As there proportion of nurse practitioners (NPs) contains practical information pertaining is a wealth of information related to child that care for children do not have to a variety of subjects that are intrinsic protection currently in the literature and extensive paediatric experience, nor to paediatric advanced nursing practice. also because of the complexity of the a children's nursing qualification. Part Two (Common Paediatric Problems] issues, the decision was made to address In formalised NP programmes, typically outlines the clinical assessment, diagnosis child protection in a reference-only there is very little paediatric content. and management of numerous paediatric approach rather than outlining its Even for paediatric advanced ambulatory conditions that are often assessment, diagnosis and management practitioners working in specialist areas encountered, assessed and/or managed (as in the other sections). This decision (e.g. paediatric oncology, dermatology, by NPs. The chapters in Part Two are was not intended to minimise the paediatric acute care, etc.) knowledge of arranged in a 'systems' format, with the importance of child protection in common paediatric conditions outside individual conditions (or presenting advanced paediatric practice, but rather the scope of their individual specialties complaints) comprising the sub-content it was an attempt to provide the NP may be lacking. Paediatrics: A Clinical of each chapter. Individual sections in the with a broad range of information Guide for Nurse Practitioners is book attempt to address their specific related to child protection that could an attempt to address these gaps and the content in a consistent format. This subsequently be applied on an individual paucity of reference material with regard objective is easily achieved in Part Two basis (concurrently with local resources to paediatric advanced nursing practice. as each topic begins with some basic and procedures). As such, the main objectives of the book background information about the While the book is not the definitive are: (1) to offer nurse practitioners (both subject and then proceeds to discuss the guide to paediatrics, it is an initial developing and experienced providers) pathophysiology, historical information, attempt to .assist both the acute care NP a pragmatic and clinically focused, important physical examination findings, (that may be queried by a mother about UK-based text that outlines important list of differential diagnoses, initial her child's eczema) and the primary care components to be considered when management, follow-up and indications NP (that may find a healthy 13 year old assessing and managing health problems for referral. This format is not so readily in the consulting room asking why she among infants, children and adolescents; applied to the topics in Part One, where has not started puberty) with the (2) to provide nurse practitioners with the subject matter does not lend itself so information required for initial information that has immediate relevance easily to this format (e.g. Internet assessment, diagnosis and management to their advanced practice in paediatrics; Resources for the Nurse Practitioner). of a range of paediatric ambulatory and (3) to furnish nurse practitioners However, it is my hope that the conditions. It is my sincerest hope that it is with a paediatric advanced nursing text practitioner reaching for this text in the useful to you in your everyday practice. that is not setting dependent (i.e. not middle of a busy clinic session, for the I welcome your feedback and your specific to primary or acute care but most part, knows what to expect and expertise, especially as it relates to the instead can be utilised in numerous where to find the relevant information. book's format, content and/or settings). While the future may see Each section concludes with a list of conditions that are not covered PART 1 CLINICAL ISSUES IN PAEDIATRICS 1 A developmental approach to the history and physical examination in paediatrics 3 2 Anatomical and physiological differences in paediatrics 8 3 Care of the adolescent 12 4 General principles in the assessment and management of the ill child 15 5 Pharmacology in paediatrics 1 8 6 Internet resources for the nurse practitioner 22 7 Paediatric telephone advice and management for the nurse practitioner 27 8 Transcultural nursing care 31 1 This page intentionally left blank 1 CHAPTER A Developmental Approach to the History and Physical Examination in Paediatrics kATIE bARNES AND fIONA sMART with toddlers or families with in order to assess the infant within a INTRODUCTION numerous children in the consultation broader context. Lastly, information • Children are not miniature adults and room at the same time. about the family's ability to cope with as such, the nurse practitioner (NP) • Table 1.1 summarises important a sick infant is requisite for the caring for children will require an developmental considerations. negotiation of a realistic plan of care. appreciation of age and development- The physical examination of a young related issues that impact the care infant (less than 5 months of age) is INFANTS (BIRTH TO 12 of children. This includes an relatively straightforward and can MONTHS) understanding of the anatomical and usually proceed in a cephalocaudal physiological differences across the age • Attachment and trust are the key manner. The examination of older groups (see Ch. 2) and a working developmental issues of infancy and the infants will likely require flexibility in knowledge of child development (see infant-carer dyad is pivotal. Therefore, the examination sequence. However, Appendix 1). This section will outline it is important that the NP respects this if presented with a sleeping infant, the the developmental springboard from relationship and involves the parent(s) in NP should take advantage of the which the paediatric history and all aspects of the physical examination. opportunity to assess the heart, lungs physical examination are launched. In addition, stranger and separation and possibly the abdomen. It is Note that Chapter 3 (Care of the anxiety play an increasingly important important to provide a warm, protective Adolescent) discusses this unique role when assessing children older than environment for the infant, as she will group in greater detail. 7 months. Stranger anxiety tends to not be happy if the examination room is • Flexibility is an important prerequisite peak at 9 months, whereas distress cold and she is undressed and exposed. to paediatric consultations; observe the related to a separation from caregivers Young infants can be examined on the child's response and let this guide your may continue to influence social table, whereas older infants (especially interactions. interactions into the toddler period. those that can sit) may be happier on • Considerations of safety are likewise Note however, that there are wide the parent's lap. It is often helpful to imperative when working with children. variations with both of these behaviours. position yourself opposite the parent Think about the proximity of electrical • A birth history (gestational age at (putting knees together) to form a outlets, equipment in the examination birth, birth weight, prenatal care, 'human examination table.' Note that if area (otoscopes, ophthalmoscopes) intrauterine exposures, problems the older infant does need to be placed and other hazards that are easily during labour, delivery or the neonatal on the examination table, be sure to reached by inquisitive fingers period) is particularly relevant in this keep the parent in full view and keep (electrical cords, lamps, needles). age group as an assessment of potential the infant in a sitting position (she will Never leave a, child unattended on the vulnerability may be necessary (e.g. not like lying down). Smile at the examination table. traumatic birth and risk for infant—she'll smile back. Likewise, be • Be organised (without forgetting about developmental delays). In addition, the sure to use a gentle touch and tone of flexibility). Equipment should be parent's observations regarding the voice. Cooperation can be assisted by accessible and in working order; things infant's growth, development and the use of distracters such as rattles, can easily slip into chaos, especially illness-related behaviours are required snapping fingers or tongue depressors. 3 Table 1.1 A Developmental Approach to the History and Physical Examination in Paediatrics Developmental Considerations Infants (birth to 12 months) Toddlers (1-2 years) Pre-schoolers (3-5 years) School~agers (6-1 f yean) Adolescents (12*-16 y&an) • Most dramatic and rapid Separation and stranger Developing sense of Sense of industry Increasing independence period of growth and anxiety continue to initiative is important important; articulate and Time of tremendous development influence social Able to 'help', participate active participant in care growth and change • Attachment and trust are interactions and cooperate Increased self-control Orientation to the future key issues Autonomy, egocentrism Knows most body parts Understands simple Separates easily from • Stranger anxiety appears and negativism are major and some internal parts scientific explanations parents >6 months developmental issues Fears bodily harm (cause and effect); Peer group important • Separation anxiety starts Parent is a 'home-base' Verbal communication thinking still concrete Knows basic anatomy to affect social interactions for explorations skills more advanced and physiology at approx. 9 months Fears bodily harm Cognition characterised Has own opinions/ideas • Safety is an issue as Verbal communication by egocentricity, literal Active and articulate gross and fine motor skills limited interpretations and participant in care development progress Safety continues to be magical thinking rapidly an important issue Age-related History Infants Pre-sc/Joo/ers School-agers Adolescents • Birth history Birth history • Family coping • Child's understanding • HEADSS history • Carer's observations of Reaction to increasing • Child's understanding of and role in illness and its • Parent/adolescent infant growth and independence illness management relationship development Family coping with toddler • Parental expectations of • School performance, • See Chapter 3 • Parental observations of issues: struggles, tantrums, illness enjoyment and presence illness behaviours negativity and discipline of any problems at school • Family coping with illness Carer perception of • Hobbies growth/development • Family coping Family stress levels and perceptions of illness A Developmental Approach to the Physical Examination • Three rules in the examination of children and adolescents: flexibility (adjust your technique according to the child's response); safety (do not leave the child unattended on the examination table, careful with outlets and equipment); and organisation (things can easily slip into chaos) Allow the child's age and developmental level to guide your history and physical examination Atmosphere and environment are important (e.g. warm room, appropriate decoration, use of toys, consider special needs of adolescents, unhurried social environment, try and limit the number of people in the room) Incorporate health education and growth and development anticipatory guidance into the examination Move from the easy/simple -> more distressing; use positive reinforcement and 'prizes' Use demonstration and play to your advantage (play equipment or 'spares', paper doll technique, crayons, blocks) Expect an age-appropriate level of cooperation; explain what will be involved in the physical examination and tell the child what she needs to do (e.g. hold still, open your mouth) Infants Toddlers Pre-schoolers School-agers Adolescents • Keep parent in view • Most difficult group to • Allow close proximity to • Usually cooperative • Give the option of • Before 6 months examine parent • Child should undress self; parental presence examination on table; • Approach gradually and • Usually cooperative; able privacy important; • Undress in private; after 6 months exam- minimise initial physical to proceed head to toe provide drape/gown provide gown ination in parent's lap contact • Request self-undressing if possible • Expose one area at a • Undress fully in warm • Leave with parent (sitting (bit by bit exposure- • Explain function of time room or standing if possible) modesty important) equipment; use of • Physical examination • Careful with nappy • Allow to inspect • Expect cooperation 'spares' helpful can be an important removal equipment (demonstration • Allow for choice when • Examination can be teaching exercise • Distract with bright usually not helpful) possible important teaching • Head-toe sequence objects/rattles • Start examination distally • If uncooperative, start exercise • Feedback regarding • Soft manner; avoid loud through play (toes, distally with play • Head-toe sequence normalcy is important noises and abrupt fingers) • Allow brief inspection of • Praise and feedback • Anticipatory guidance movements • Praise, praise, praise equipment with brief regarding normalcy is regarding sexual • Have bottle, dummy or • Parent removes clothes demonstration and important development (use Tanner breast handy • Save ears, mouth and explanation staging) • Vary examination anything lying down for • Use games/stories for • Matter-of-fact approach sequence with activity last cooperation to examination (and level (if asleep/quiet • Use restraint (with parent) • Paper doll technique very history) auscultate heart, lungs, only if necessary effective • Encourage appropriate abdomen first) • Praise, reward and decision-making skills • Usually able to proceed positive reinforcement in cephalocaudal sequence • Distressing procedures last (ears and temperature) 4 sCHOOL-AGER (6-11 YEARS) Avoid loud noises, jerky movements parts of the physical examination are understanding of what made her and blocking the infant's view of the and set these as a priority. Avoid unwell. Discuss parental expectations parent. Save distressing manoeuvres becoming involved in a power struggle of the illness as part of the history in for last. by having the parent undress the child. order to obtain an idea of whether Begin the examination distally, and these are appropriate for the child's work towards the centre of the body. age and illness course. Keeping the toddler's fingers busy • The physical examination of the pre- TODDLERS (12 MONTHS TO through playing with the blocks, may school child can be quite fun. It is 2 YEARS) lessen the likelihood of the stethoscope likely that the pre-schooler will be • Developmental issues impacting the being pulled out of your ears. Leave quite comfortable on the examination physical examination of toddlers the examination of mouth, ears and table (but be sure to keep mother close are a function of their growing any system which requires the toddler at hand) and that the physical independence, characteristic negativity to lie down until last. Use restraint examination can proceed in a head to (as an expression of emerging (with the parent's permission and toe direction (although sometimes it is autonomy), egocentricity and fear of assistance) only if absolutely essential. best to save mouth and ears for last). bodily harm. In addition, separation Praise is important, as are calm and Privacy is an issue, so it is probably and stranger anxiety continue to reassuring tones. best to undress one part at a time (the make social interaction challenging. child can do this); if the child is very The parent will be a 'home base' hesitant, start with the shoes (or for exploration as the toddler proceed as with the toddler). Allow PRE-SCHOOLERS alternates between investigation the child to play with and inspect (3-5 YEARS) and parental reassurance. the equipment (it is very handy to Communication is restricted by a • Interactions with the pre-schooler are have a 'spare' play stethoscope). It is limited vocabulary and, as verbal skills far easier than with toddlers. Fear of important to explain to the child what are insufficient for expression, the bodily harm remains an issue, but most will be involved when the heart, lungs, toddler will physically act out fear, pre-schoolers are outgoing and abdomen, etc., are examined; upset and anxiety. unafraid as long as contact with the demonstrations on a nearby doll • Important historical information to parent is maintained and they are told (or the tracing of the child) can be obtain in the assessment of toddlers what is going to happen. invaluable. Allow the child choice includes much of the same information Communication skills are far more when possible: 'Which should we listen included with infants (e.g. birth advanced and the pre-schooler will to first, your heart or your lungs'?}. history, growth and development know most body parts (including Praise and positive reinforcement history and illness behaviours). some internal ones). Games can be throughout the examination will not However, some additional information used to very good effect, including only have pay-offs for the immediate is necessary in order to best negotiate storytelling, colouring and the 'paper consultation, but also will set the tone a plan of care: parental reaction(s) to doll technique' (i.e. the child's outline for future interactions. The pre-school the toddler's increasing independence; is traced onto the examination table period is when the foundations of the the extent of tantrums/struggles and paper for explanations and building patient-NP relationship can take handling of discipline; difficulties with rapport). The pre-schooler's shape. As such, the expectation is that the toddler's degree of negativity; and developing sense of initiative can the child is an active and positive family stress levels (e.g. a family that is likewise be used positively; praise the participant in her own health (and struggling with developmentally child for being so 'brave', 'grown-up' health care) which is an important appropriate tantrums and negativity and 'helpful'. The pre-schooler can concept in the development of healthy may find the added stress of illness- follow simple instructions (e.g. lifestyle choices. related irritability very difficult). dressing, undressing, putting toys • Toddlers are the most difficult age away) and again these behaviours group to examine. Start with a gradual should be praised and/or rewarded SCHOOL-AGER (6-11 YEARS) approach, initially avoiding eye contact (child-friendly stickers are a big treat). with the toddler while smiling and Note however, that cognition may be • These children are usually willing speaking happily with the carer. Setting characterised by egocentricity, literal participants and curious about what is out distracters, such as blocks or other interpretations and magical thinking; involved in their physical examination toys (remember infection control communication should be direct, clear and care management. They are principles) during the history (while and unambiguous (e.g. checking your articulate and possess much greater still avoiding direct eye contact with temperature rather than taking your self-control (as compared to the the toddler) allows the child to temperature). younger age groups). Their sense of become more familiar with you before • Additional history specific to the accomplishment and mastery is the examination is attempted. pre-schooler includes family coping important and they will understand Consider what the most important with the illness and the child's simple scientific explanations 5 1 A developmental approach to the history and physical examination in paediatrics (i.e. cause and effect). However, their The physical examination of the do in clear, unambiguous terms. Praise thinking remains concrete (although adolescent is similar to that of an adult. children for cooperative behaviour and there is wide variation in older It is important to use it as an note that small 'prizes' (i.e. stickers) children) and validation should be opportunity for health education and can be good motivators and sought as to whether the child anticipatory guidance; be sure to reinforcers. understands what has been discussed: reinforce normal findings. The i.e. 'Can you explain back to me adolescent is likely to be very self- what you need to do to take care of conscious and extra consideration BIBLIOGRAPHY your coldr'. should be given to privacy: e.g. allow It is important to elicit from both the the adolescent to undress in private, Algranati PS. The pediatric patient: an parent and the child what they believe expose a single area at a time and approach to history and physical is responsible for the illness and how provide drapes and gown. Explain to examination. 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