Introduction to Nursing Care of Pediatric Patients

Pediatric nurses carry a heavy responsibility for caring not only for the vulnerable, highly diversified pediatric population with complicated and intermingled medical needs but also for understanding the importance of this particular group’s emotional needs. Pediatric clients’ emotional needs must become the top priority. 

Nurses are tasked with advocating for and providing for the best interests of this sometimes fragile population. This is accomplished by decreasing the stress and fear reactions that might occur if nurses do not strategize before caring for a child. For example, one in 10 children (and adults) has a significant fear of needles that causes them to avoid necessary medical care [11]. Although regression is expected with hospitalized children of all ages, it is the nurse’s responsibility to foster growth and acclimation within the healthcare setting. 

Taking the time to address children’s emotional needs before any hands-on procedure (or even touching the child) respects the child’s personal space and earns their trust. 

This course will address many aspects of developmentally appropriate interventions with the pediatric population in a layout that is easy to comprehend and utilize in your practice. Many children are resilient but must be given a sense of control to build trust with healthcare providers. 

The primary guiding principle is to involve families in the care as the basis of creating a solid relationship with the child and facilitating treatment success. The secondary guiding principle is nurses must allow children to express the way they feel [15]. This may be difficult as some children may not be equipped to express their feelings depending on their age. They may not have the vocabulary to express those fears, anxieties, anger, happiness, and other feelings. For this reason, children should be guided express these feelings if not with words, then with activities, otherwise these feelings are likely to result in negative behavior.  

This course will provide up-to-date ideas, suggestions, and activities to improve your care to the pediatric population. 

Current Practice in Nursing Care of Pediatric Patients

According to the Centers for Disease Control (CDC), in 2023, 6% of children under age 18 had at least two or more emergency department visits [33]. While this number is down from 6.7% in 2019, percentages are rising again from 4.7% in 2020, 3.6% in 2021, and 5.2% in 2022. Many pediatric clients admitted to hospitals have complex care needs (i.e., physical, psychological, and social). The nurse must ensure all of the child’s needs are met, including those outside of routine medical care [19]. 

Currently, nurses face increased client caseloads in the hospital, homecare, and clinic settings, and consequently, their time is at a premium. The suggestions for interventions in this course will assist the nurse in providing timely care and diminishing emotional meltdowns by understanding the child throughout their stage of development. 

Protective Factors in Children 

The way a nurse approaches their clients can do a great deal to encourage a frightened or wary child. Research has shown that some children develop resiliency or the ability to overcome grave hardship while others do not [6]. However, when well supported, children who have difficulty are better able to overcome adversity and traumatic events. Protective factors can decrease the likelihood of children experiencing these adverse childhood events [8]. 

These protective factors may be [8]:  

• Individual: basic needs met; supportive, nurturing, and safe relationships with parents/guardians 
• Relationship/Family-Related: strong social support networks; positive relationships with those around them; role models and mentors outside of the family 
• Community-Based: access to safe housing, medical care, and financial help 

Through adversity, children can learn how to process life based on their own experiences, how they have dealt with those experiences in the past, and responses from others such as parents/guardians, nurses, and other healthcare providers. In short, children use these events to reflect back positively on future stressful experiences. 

Challenges in Pediatric Nursing 

A pediatric nurse deals not only with the child but also with all the anxieties and demands of the parents/guardians. However, when parents/guardians perceive that nurses support them, their confidence in the nurse rises, making caregiving less stressful for the nurse [36]. This has also been shown to lead to positive outcomes for the child.  

Nurses are also faced with workplace challenges that lead to unintentional care deficits. Evidence shows that, along with higher nurse-to-client ratios, unexpected client volumes, other staffing and workload issues, and frequent interruptions to care, these lead to suboptimal pediatric nursing care [29]. These missed care activities include oral care, routine bathing, and adherence to infection control measures.  

Nurses experience intense stress in completing their vital tasks with clients, and this is another factor in their ability to deliver quality care. Hospital administrators, nurse managers, and nurses themselves must address this level of stress and the time constraints to facilitate quality of care. Children are equipped with abilities to detect hidden stress, and this reflects how they perceive and react to a given situation. 

Family Responses to Illness and/or the Hospitalized Child

It is the nurse’s responsibility to promote a sense of security in pediatric clients. In fact, it is the most important item on their to-do list for pediatric clients in the healthcare environment. Feeling secure depends on a sense of physical and psychological safety.

Parents/guardians are vital to promoting this safety in the pediatric client. Parents’ presence at the bedside is the best way to decrease anxiety and increase children’s sense of security. Nurses must do everything in their power to decrease parental stress and anxiety, which will directly impact the child’s positive coping abilities.

A healthcare facility has many members who can provide support to a family with a sick child. For example, child life therapy, social work, chaplain support, and interprofessional support can all supplement a family’s needs [39].

Adapting to the Hospital Environment 

In order to help families adapt to the hospitalization of the child, the nurse should:

• Build Trust: Build trust with the family by communicating frequently with them, including siblings. This includes education in simple, concrete facts that encourage parents/guardians to ask questions. The nurse should ask open-ended questions to the child, parents/guardians, and siblings.
• Encourage parental presence: Understand that parents’ presence in their child’s hospitalization is an extension of the child, and the child must make sense of what is happening to them.
• Encourage family check-ins: If parents or guardians are staying at the hospital, encourage them to stay in touch with siblings at home.
• Involve siblings: Establish a relationship with the sibling and explain the medical condition of their sibling in simple terms. Also, include the sibling in therapy with the client so the sibling feels they are helping their sick sibling.
• Instill hope: Instill a sense of hope in parents/guardians by carefully choosing words that elicit hope.
• Remain positive: Focus on the positives in every situation.
• Encourage frequent visitation: Encourage parents/guardians to visit their child anytime, stay overnight, and/or call the nurse for an update. Nurses need to assess how much parents/guardians would like to be involved and support their choice. However, evidence shows that parental separation during hospitalization leads to stress and anxiety in children, and the compounding effects of hospitalization and separation can cause distress and trauma even after hospitalization [2][30].
• Identify decision-makers: Identify key family members and decision-makers in the child’s care.
• Teach communication strategies: Teach parents/guardians how to talk to their child about the medical procedures, equipment, status, and health concerns. Prepare parents/guardians ahead of time for tough conversations with children to lessen both the parent’s and the child’s anxiety level.
• Reduce anxiety: Teach parents/guardians how to talk calmly, how to touch to calm the child, and the power of eye contact (note: while eye contact helps to keep young children engaged, the nurse should consider the child’s cultural background when engaging in eye contact as culture often defines the appropriateness of this action) [24]. Parents/guardians have a key role in lessening anxiety through coping skills. Children can sense parent’s emotional upheaval so working to lessen parent’s emotionality is crucial to helping children cope. Parents/guardians and nurses need to respond to an anxious child with empathy, compassion, and acknowledgement.

Alleviating Anxiety 

Here are some examples of how to address anxiety in hospitalized children [22]: 

Table 1. How to Alleviate Anxiety in Hospitalized Children [22] 

Ensuring a Therapeutic Relationship 

According to Fletcher et al., as cited in Dryden (2024), to ensure a therapeutic relationship with children, nurses should employ these strategies [45]:

• Be friendly, approachable, kind, and caring
• Be able to talk and listen
• Be an “expert,” but be “cool.”
• Be reassuring and supportive
• Keep a professional appearance (look like a nurse) (note: when children draw a nurse, most drawings will show someone in the traditional nursing uniform)
• Communicate age-appropriately and recognize the child’s needs (such as “alone time” for adolescents) (we will discuss this in greater detail later)
• Explain what is happening
• Promote self-care

Developmental Considerations for Appropriate Nursing Care of Pediatric Patients

Some interventions and principles hold true for children of all ages. Pediatric nurses should strive to incorporate these principles into their practice regardless of the child’s stage of development. These include but are not limited to, communicating in age-appropriate language, establishing routines, and being humorous.

Standard Pediatric Care Strategies 

• Communicate age-appropriately: Children grasp information best when it is appropriate to their cognitive level of development. Simple explanations about their medical condition and the plan for the day can help children feel included and understood [19].
• Instill independence: Offer choices to every child when performing even routine tasks such as obtaining their blood pressure. This will promote a sense of control in the child. Ask, “What arm would you like me to use to check your blood pressure?” Instilling independence in children with serious illnesses is particularly important as these children experience low self-esteem and lack of independence and resilience compared to their healthy peers [4].
• Establish routines: Create a daily schedule so that the child is aware of what to expect throughout their day. (see more below)
• Be humorous: Use humor and laughter to lighten up the air with children.
• Encourage music therapy: Offer the option to listen to music just prior to surgery if feasible as this has been shown to lessen preoperative anxiety in both children and teenagers [25].

Children need a regular schedule in the hospital that mirrors home life as much as possible but that is also consistent from day to day in the hospital setting. In one study, nurses collaborated with parents to maintain a familiar rhythm and routine for their pediatric clients, including bringing familiarity to mealtimes, maintaining sleep patterns and activities of daily living routines, and facilitating play and activities [43]. This not only creates a home-like environment for the child, bringing comfort and feelings of safety, but it also contributes to positive professional relationships between nurses and parents/guardians, which leads to positive health outcomes for the child [3].

Initial Interactions with Pediatric Clients 

Here are some general tips for pediatric nurses to keep in mind when initially meeting the pediatric client:

• Remain at eye level: Nurses should physically stoop down to the child’s level. Eye-to-eye contact is important to develop a trusting relationship. A short stool works well to get at their eye level.
• Engage in small talk: Introduce yourself and ask the child personal questions such as “What is your favorite toy?”, “Who is your favorite cartoon character?” or “What is your favorite school subject or sport?”
• Smile: Nurses should smile at their pediatric clients [17]. Children of all ages, from babies to adolescents, appreciate this approach. Who doesn’t like a friendly, calm approach?
• Acknowledge names: Regardless of the child’s age, use their name. It soothes children and parents/guardians alike. It shows respect for individuality and lessens anxiety in children and parents/guardians. Never refer to a child by their diagnosis.

Additional Tips for Pediatric Nurses 

Children of all ages, from toddlers through adolescence, love to help. Through their role in their own care, it can alleviate stress and build trust. Actively participating in the plan of care can make children feel safer and more content with their hospital experience [19]. For example, the nurse can ask the child to hold their otoscope until it is needed. Teach them the tools of the trade. The nurse can try these other strategies:

• Elicit help: Say, “I need your help to stay very still. Can you do that?” This activates the child to engage in your activity with helpfulness.
• Try Animal therapy: When appropriate, consider using a therapeutic dog in the hospital setting as a distraction and calming technique. Animal-assisted therapy has been shown to improve the level of stress and anxiety in children, motivate them to participate in physical activity, and encourage them to feel safe enough to share their worries [26]. Check with your facility for approval of canine therapy or get permission for the child’s dog to visit the playroom.
• Involve in decision-making: Give children the same time and respect you would give adult clients [1]. This includes decision-making even when they cannot make decisions on their own. This will enhance their sense of control over their own health. As mentioned earlier, children should be encouraged to participate in their plan of care as this can help them feel safer while hospitalized [19].
• Be honest: Secrecy and dishonesty can increase a child’s sense of anxiety and fear and undermine trust with the nurse. However, being 100% honest with children about their condition or prognosis is controversial, as some experts feel children should not be exposed to distressing information [16]. This may be cultural as well. While honesty is the best policy as it shows respect for the client, many health experts suggest keeping the child’s best interest in mind when choosing which information to disclose [16].
• Elicit questions: Nurses should coach children to ask more questions and thereby increase satisfaction with their healthcare providers.
• Give respect: Never talk down to a child, for example, in a singsong voice. This is demeaning to them.
• Provide familiarity: Encourage parents/guardians to bring posters, photographs, and other items from home to personalize the bedside. This may help the child to feel more comfortable in the hospital setting.
• Encourage roommates: If possible, choose roommates for children to promote socialization and foster growth. Sometimes, nurses can advocate for children with similar disease processes or hobbies to room together in the hospital. This promotes a sense of community, facilitating recovery and belonging. Be sure to comply with infection control measures.
• Provide reassurance: Remind children that their illness is not punishment. Explore this confusion in your pediatric clients. Sometimes, children do not have the words to express their fears that they did something wrong to cause their illness or hospitalization. Be sure to consider the child’s thoughts and feelings about illness may be influenced by cultural beliefs surrounding illness or disease [24].
• Communicate age-appropriately: Use words and sentence lengths that match the child’s level of understanding. For example, a five-year-old child may engage in conversation and speak sentences up to eight words long, whereas a two-year-old child might only answer simple questions and speak three-word sentences [42].
• Drawing and coloring: Use crayons and paper freely. First, demonstrate by drawing yourself and encourage the child’s expression.
• Provide comfort: Give children time to feel comfortable with you. Speak to the parents/guardians first.
• Give encouragement: Help children understand they can face their fears. Promote courage by stating, “I know you’re scared, and I’m here to help you.” [22]
• Give Praise: Give hope and courage to children through praise by stating how “brave” and/or “good” they are.
• Engage in Play: Communicate with puppets, dolls, or stuffed animals first before asking a young child questions directly.
• Ease discomforts: If a child is ticklish when you are examining their abdomen, place the child’s hand down first on his own abdomen and place your hand on top of his. Then, slowly deviate from his hand to examine the abdomen.
• Avoid restraining: Try alternatives to restraining/holding children down for routine clinical procedures. Evidence suggests controversy still exists regarding restraining/holding a child down against their will for non-urgent clinical procedures [14]. Some nurses perceive pressure from parents/guardians to do so, which places the nurse in a morally conflicting situation. Nurses should prioritize the child’s safety and consider the expectations of the parents/guardians as well as facility practices/protocols.
• Encourage free choice: Allow children to pick a toy out of the toy box to play with during the procedure, and then afterward, they can pick a gift out of the box and return the toy.
• Consult other team members: Involve the medical social worker to assist in therapy with pediatric clients.
• Avoid shaming: Tell children it is okay to cry; do not shame them for expressing this emotion. Be sure to consider the child’s cultural background, as some parents/guardians may discourage their children from crying or expressing emotion (more on later).
• Give explanations: Stress the positive benefits of procedures, for example, “After this bandage change, your sore will heal quicker.”

The Importance of Caring, Consistency, and Humility

Children of all ages must feel a sense of love from their caregivers. Children are barometers of the emotions of the people around them. These emotions can influence negative behavior in hospitalized children. Negative behaviors are also influenced by the child’s inability to handle their feelings, sensory overprocessing (when their senses are overwhelmed), trauma, or psychological disorders [32].

Feeling comfort and safety from nurses and caregivers is a basic tenet but vitally important to working effectively and compassionately with the pediatric population. Children are more likely to push past anxiety and have a sense of safety if surrounded by genuine, caring nurses. Love can best be demonstrated in those quiet moments shared with children, holding, stroking their arms, and/or sharing some fun activity. Some children are more resilient than others, but basic emotions of love and trust can foster this resiliency [6]. Sometimes, one successful episode is all a child needs to feel they can complete a procedure or tackle the impossible.

How can nurses show kindness yet firmness? How can they show empathy and respect? These personality traits flow from an individual’s inner core but can be learned. Humility allows nurses to offer choices to both parents/guardians and children. This MUST be kept in mind when working with the pediatric population because it will give both parents/guardians and children a sense of control.

Labeling Feelings

As aforementioned, children may act out if they are unable to regulate their own feelings [32]. Helping children understand their feelings and label them is an instrumental step in helping them gain control of the situation and their emotions. Using a “feelings chart” can help the nurse identify the child’s emotions at the time.

Similar to the Wong-Baker Faces Pain Rating Scale, a feelings chart includes a set of cartoon-like faces that children can point out. These faces express certain emotions, such as anger, frustration, happiness, sadness, confusion, disappointment, and others [13][37]. The chart may be facility-specific, and some include a worksheet that helps children identify what happens in the body when they experience certain emotions, such as smiling when happy, fist-clenching when angry, cheek-blushing when embarrassed, and leg-shaking when afraid [37]. Children should be assured that feelings are normal and not “bad.”

Let’s Talk About Resiliency

Nurses need to assess a family’s resilience. Resilience is described as a process that enables successful adaptation and flexibility when meeting risks or threats [31]. Nurses can help families learn new skills, reinforce confidence in family members to deal with the stress of illness or injury in the child, and encourage family members to see their strengths and transfer competence from their past stresses in life to this event. 

Understanding Resiliency in Children 

Regarding the child alone, Masten et al. (as cited in Mesman, 2021) describe a list of resilience factors that may help nurses understand some children’s ability to remain strong in the midst of illness and hospitalization. Resilient children are those who [31]: 

• Have experienced sensitive caregiving 
• Have close relationships and social support 
• Feel a sense of belonging and cohesion 
• Are able to self-regulate 
• Have problem-solving skills 
• Engage in active coping 
• Are hopeful and optimistic 
• Have confidence in a better future 
• Are highly motivated to adapt 
• Have a sense of meaning and purpose 
• Have a positive view of self and family 
• Engage in positive habits, routines, rituals, and traditions 

Building Resiliency in Children 

There are strategies to strengthen resiliency in children, and by doing so, children are less anxious, better behaved, and more in control. An important key reminder about resiliency is that no one is born with it. Resiliency is developed over time with each success. Each positive opportunity, and even small words, can grow it. Children do not need parents/guardians (or nurses) to solve their problems. Resiliency is enhanced when children solve their own problems.  

How do you build resiliency in kids? Experts identify play as a core strategy for building resiliency in children of all ages. Play provides an avenue for children to gain a sense of mastery and control over their own world [5]. Play involves learning, exploration, discovery, and creativity. According to Harvard University experts, resiliency is described as more than being able to cope with things that are expected; it is being able to handle the unpredictability of life [5]. This is how play helps to build resiliency. Play is a way of thinking and engaging with the world, continuing throughout the lifespan [5]. As children navigate through life, they automatically set the basis for resiliency. 

Nursing Care of Infants (0-12 months)

Infants are totally dependent on their caregivers. Their bodies and immune systems are immature and vulnerable to illness and trauma. Infants cannot verbalize their needs, making identification of health problems highly critical. Infants are most vulnerable during their first 28 days of life (note: “neonate” refers to infants in their first month). The following are health risks specific to infants based on their stage of growth and development with associated nursing assessments and interventions [3]. 

Infection 

Neonates are the most susceptible to infection. Nurses/clinicians should monitor for neonatal sepsis during this time (irritability, poor feeding, lethargy, high or low temperature), prepare a full septic workup if present (pan cultures), and anticipate administering antibiotics. Sepsis prevention in the newborn is achieved by limiting visitors during the first 28 days after birth and avoiding antipyretics, which can mask fevers. 

Failure to Thrive 

Infants are at risk for failure to thrive (FTT) depending on the home environment (neglect, poor finances), medical conditions (malabsorption, food allergies), and suboptimal feeding. FTT refers to inadequate weight gain or sudden weight loss consistently below the fifth percentile for age and sex. Nurses/clinicians should perform a thorough history and physical to assess these risk factors and involve social services if needed. 

Sudden Infant Death Syndrome 

The infants’ total dependency on caregivers and their inability to reposition themselves in their crib increases the risk of sudden infant death syndrome (SIDS), also called crib death. SIDS occurs when the infant suddenly dies, most often during sleep, without an identifiable cause [10]. SIDS is the third leading cause of death in infants under age one in the U.S. Risk factors for SIDS include low birth weight, being too warm while sleeping, and sleeping with loose blankets or on soft surfaces. Nurses/clinicians can help prevent SIDS by educating parents/guardians about safe sleep practices (positioning the infant on their back on a firm mattress with a fitted sheet and keeping items out of the crib that can cause suffocation). 

Shaken Baby Syndrome 

Due to infants’ dependency on their caregivers for survival, they are more susceptible to abuse and neglect than older children. This can range from unintentional underfeeding to intentional physical harm. Shaken baby syndrome is a form of abuse in which an infant’s caregiver shakes them out of anger or frustration [7]. Infants’ neck muscles are weak, rendering them unable to hold up their heads, leading to potentially serious injuries, such as brain injuries and bleeds, retinal bleeds, and head/facial fractures. Nurses/clinicians should perform a thorough family assessment, identifying potential abuse, caregiver burnout, or support needs, and make referrals as needed (social services, support groups, babysitting services). 

Nursing Care of Toddlers (1-3 years) 

The toddler years are full of exploration. During this time, children are more mobile, and their diets are changing, which makes them more susceptible to accidents and malnutrition. The following are health risks specific to toddlers based on their stage of growth and development, with associated nursing assessments and interventions [3]. 

Accidental Injuries 

Unintentional injuries are the leading cause of death among toddlers in the U.S. [34]. This can include suffocation, drowning, falls, poisoning, and fires. Parental/guardian education is the primary prevention strategy nurses can employ to keep toddlers safe from accidents. While children should be allowed to play and explore, the importance of child supervision should be stressed to parents/guardians. Contact information for poison control centers should be provided in an emergency. 

Malnutrition 

Toddlers’ diets begin to change as they begin to feed themselves. They begin to have food preferences and can become selective with the types of food they eat. Children in this age group are more at risk for malnutrition (either too much or too little nutrients). Adequate iron intake is critical for this age group, as deficiency can cause delayed growth and development, including learning and memory problems [41].  

Nurses/clinicians should perform a thorough family assessment to screen for financial difficulties (which may contribute to poor nutrition) and make referrals to social services for financial assistance programs as needed. Educating parents/guardians about the importance of an iron-rich diet is also vital. Iron-rich foods include iron-enriched cereals, grains, meats (beef and organ meats), poultry, fish, legumes (peas and beans), and green leafy vegetables [41]. 

Nursing Care of Preschool Children (3-6 years)

Preschool children become even more active than in their toddler years, making them susceptible to accidents. They also begin to be more social. They start school and socialize and play with other children in large groups. This makes them more susceptible to contracting illnesses from others. The following are health risks specific to preschool children based on their stage of growth and development with associated nursing assessments and interventions [3]. 

Accidental Injuries

As with toddlers, unintentional injuries are the leading cause of death among preschool children as well [34]. Injuries specific to this age group (aside from suffocation, drowning, falls, poisoning, and fires) include foreign bodies in body orifices and swimming injuries. While preschoolers spend a good amount of time playing with other children at school, evidence shows many childhood injuries actually occur in or around the home. Therefore, nurses/clinicians should continue to educate parents/guardians on the importance of child supervision.  

Communicable Diseases 

Preschoolers tend to become ill often as they frequently socialize with other children, where germs can spread. Although their immune systems get stronger with age, they have yet to be exposed to many pathogens. Preschool children are highly susceptible to respiratory viruses, head lice, gastroenteritis, and hepatitis A. Isolating children to avoid illness is not advisable.

Therefore, the nurse/clinician’s primary role in preventing communicable disease in this age group is educating parents/guardians on the importance of hygiene (especially hand washing after bathroom visits) and childhood immunizations. Nurses/clinicians can also teach parents/guardians how to assess their child’s head for lice. 

Nursing Care of School Age Children (6-12 years) 

School-age children are highly engaged in school and more independent of their parents/guardians. This includes selecting food options and performing their own ADLs, such as brushing their teeth, bathing, and dressing. Because of this independence, school-age children are at risk for poor nutrition and health conditions related to poor hygiene (i.e., dental cavities). Issues with school learning may also be present in this group. The following are health risks specific to school-age children based on their stage of growth and development with associated nursing assessments and interventions [3]. 

Learning Disabilities 

This is the stage of development where learning disabilities are identified/diagnosed. Learning disabilities are differences in an individual’s brain that affect their ability to read, write, speak, and perform other tasks well [18].  

Some learning disabilities include [3][18]: 

• Dyslexia: difficulty with staying attentive or organized; difficulty with math or reading 
• Dysgraphia: writing impairment 
• Dyscalculia: difficulty understanding numbers and math 
• Speech/verbal apraxia: speech impairment 
• Central auditory processing disorder: difficulty understanding language-associated tasks, like explaining things, understanding jokes, and following directions 
• Nonverbal learning disorders: difficulty understanding facial expressions and body language 

Nurses/clinicians should perform a thorough history and physical to determine if the child’s learning disability is associated with a medical problem first, such as visual or hearing impairments. Children should be referred to the appropriate specialist (i.e., learning disability specialist, optometrist, otologist, etc.) as early diagnosis and treatment can minimize the disability’s impact on the child’s academic performance. 

Poor Hygiene 

School-age children perform their own personal care independently of their parents/guardians. For this reason, children must be instructed on adequate hygiene practices. Nurses can provide education to children directly as well as to parents/guardians. Topics can include wearing clean clothes, brushing teeth daily, and bathing. Consideration should be given to children’s cultural practices, which may conflict with standard hygiene practices. Nurses/clinicians should also consider poor hygiene may be a sign of neglect or financial difficulties in the home and make referrals to social services as needed.  

Nursing Care of Adolescent Children (12-18 years)

Adolescents/teens are beginning to form their own identities separate from their parents/guardians. Their peers highly influence them, and they tend to engage in risky behaviors, particularly if their peers are engaging in these same behaviors. During the teen years, children’s body is changing rapidly, including the onset of puberty. These factors alone can heighten the risk of disease and injury in this group. The following are health risks specific to adolescents based on their stage of growth and development with associated nursing assessments and interventions [3]. 

Risky Behavior 

Evidence suggests that risky behavior in teens is related to a gap between their biological and social maturity. Because adolescents do not have the extensive life experience to understand the consequences of their behaviors, they tend to underestimate risks. Common risky behaviors among adolescents include having unprotected sex and using drugs and alcohol. For this reason, nurses/clinicians should educate teens about the consequences of these behaviors and encourage parental/guardian involvement where appropriate. Performing a thorough social history and STI screening is vital in this age group. 

Identity Crisis 

Adolescents are forming their identities and may have conflicting feelings about their identity. They may struggle to create a separate identity from their parents/guardians while maintaining the parental relationship. Adolescents are at risk for self-harm due to hormonal changes (which can drastically affect mood) and identity crises.

Other factors include challenging home environments, difficult relationships with parents/guardians, mental health conditions, social isolation and lack of friends, and poor school performance. Nurses/clinicians should perform mental health screenings (such as depression screening), ask teens about their home environment, perform family assessments, and involve social services as needed. 

Therapeutic Play in Nursing Care of Pediatric Patients

Children use play to make sense of their world and to categorize the collective whole of their being with their interactions, dreams, missteps, and joyful attitudes. This play must be facilitated by the nurse when caring for the youngest of clients. Play is very individualized, with each child deciding their favorite play activity. Therapeutic play enhances the overall hospital experience for pediatric clients by enhancing coping skills, reducing anxiety and psychological distress, promoting emotional expression, and facilitating communication [38]. Play therapy also allows the child to receive validation from the nurse, building rapport between them both [20][38]. 

Structured Versus Unstructured Play 

Play should be both treatment-focused (structured) and recreational (unstructured). Treatment-focused play aims to help the child cope with their illness and hospitalization. These activities are often provided as a form of physical rehabilitation or exercise training (i.e., for children with chronic conditions) or as diversional activities to reduce the child’s anxiety/stress and/or improve their mood [20]  

Recreational play, also termed “free play,” helps to meet the child’s basic social needs [19]. Nurses should consider that although treatment-focused play may be easily integrated into the plan of care, unstructured/recreational play may be difficult in the hospital setting due to [20]: 

• Structural and cultural factors (such as infection control practices) 
• The child’s unfamiliarity with the hospital environment 
• Personal restrictions related to the child’s illness 

Here are some examples of therapeutic play: 

• The child uses the IV catheter on their doll or stuffed animal. Allowing the child to play with the equipment for several days before the procedure assists in the child’s successful processing of the procedure. 
• Stories can be read to the child, or the child can make up their own story about the healthcare event. 
• Puppets are especially useful for children to act out what they are experiencing in the hospital setting. Nurses can also have the puppets ask personal questions of the child, and it is more likely the child will answer them. 

Expressive Therapy 

Expressive therapy can be considered a form of play that works well with children oftentimes because it allows them to externalize their thoughts and feelings, which might otherwise be difficult to express at their age [38]. Here are some examples of expressive therapies that can help children address fear, anxiety, stress, and pain: 

• Art therapy 
• Drama therapy 
• Play therapy 
• Music therapy 
• Poetry therapy 
• Sand play therapy 

Play Therapy Using Medical Supplies 

While acting out medical procedures using dolls or puppets is a common strategy for engaging children in medical play activities, medical supplies/devices can also be used to create fun projects for children so they become comfortable handling these items or having them attached to them. The following, borrowed from World Eye Cancer Hope, are fun play activities nurses can teach parents/guardians to normalize medical supplies for when the child is in the hospital or receiving medical care at home [21].  

Note: Nurses should consider their facility’s infection control practices, fire safety protocols, waste management programs, and other workplace policies before attempting these activities. They should also consider the child’s age and associated safety risks (e.g., poisoning or choking). 

• Syringes:  
  • Fill with paint to create splatter art. 
  • Fill with water or bubble solution for fun water play. 
  • Fill with icing to decorate cupcakes or cookies. 
• Eye droppers: 
  • Fill with paint and drop paint colors onto a piece of paper, into a bowl of milk, or onto clothing to create tie-dye and other artwork 
• Anesthesia masks: 
  • Dip in bubble solution and create bubbles by breathing in slowly and breathing out to make the bubbles. 
  • Design into a fun character using paint and other crafts 
• Specimen containers: 
  • Fill with baby oil, glitter, and water to create a “calming jar.” 
  • Fill with small items such as uncooked rice, dry beans, and/or colorful beads. 

Cultural Considerations

It is imperative that nurses consider the cultural influences of the children they care for in the healthcare setting. This is termed “culturally responsive care” and is defined by McMillan as a framework that encourages nurses and other healthcare professionals to respond to the client’s unique cultural identity while engaging in self-reflection, as cited in Chen et al. [12]. Cultural competence, however, is a learning process.  

According to Vanderbilt University, cultural competence is “an ability to learn from and respectfully relate to other cultural backgrounds, heritages, and traditions,” as cited in Chen et al., para. 2 [12]. In pediatric care, this refers to the culture of the child and their parents/guardians and how customs influence the family’s health care decisions.  

Nurses can learn to provide culturally responsive care through direct clinical exposure and immersive experiences with children and their families [12].  

Reducing Pain and Discomfort 

Any measures to reduce pain and discomfort are the nurse’s responsibility. Nurses must assess both parents/guardians and the child for the level of security, fear, and resistance to the procedure. Nurses must support children through parental/guardian participation and communication [17]. Untreated pain in children may lead to poorer cognition and motor function as well as an increased risk of chronic pain, anxiety, and depressive disorders in adulthood [23]. Evidence even shows that when premature infants are exposed to pain, they report higher pain during needlesticks by the time they reach school age [23].  

Pain Expression by Stage of Development 

Children express pain differently depending on their stage of development. For example, infants communicate distress by crying. Parents/guardians may be able to differentiate between cries related to pain, hunger, or tiredness [17]. Therefore, parental/guardian involvement is vital for pain assessments in this age group.  

As children age, they begin to learn language, allowing them to verbalize their pain. Young children may use words such as “hurt,” “ouch,” or “ow” [17]. These children are often unable to comprehend the word “pain” enough to describe their own pain. For this reason, nurses can use the Wong-Baker Faces Pain Rating Scale – which allows children to point to a cartoon face that best describes how they feel. As the child ages, they may be able to state that they have pain but struggle with describing its location, intensity, type, or quality [17]. 

The following are typical signs of pain expression from children in various stages of development [17]: 

• Birth to 2 years: These children socially withdraw when in pain. Changes in sleep, eating, and activity levels may also occur. By 18 months, children can vocalize pain, and by age two, the child can use specific words to express pain. 
• Age 2 to 7 years: These children tend to seek comfort from parents/guardians when in pain (although those older than age 3 may begin to self-soothe). Often, children of this age range have trouble using pain scales and differentiating between pain and other discomforts, like fear. Also, they sometimes view pain as punishment for wrongdoing. 
• Age 7 to 11 years: These children begin to understand why certain types of pain, like facial pain, may be relieved by a specific type of pain medication for the face, like a cream, versus an oral medication. They also have the ability to distract themselves when in pain. 
• Age 11 and older: These children begin to understand the psychological aspects of pain. They also tend to worry about pain more than children in other age groups as they have the ability to focus on future events. 

Cultural Influences on Pain 

Earlier, we discussed the cultural implications of pediatric care. Nurses should consider that pain communication and socialization may be influenced by culture/family as well. Children of parents/guardians who make pain “catastrophic” tend to struggle in their ability to cope with pain [17]. In some cultures, children may learn that communicating pain is not acceptable or should be communicated in a particular way. For example, parents/guardians from some cultural backgrounds may view lengthy crying as unacceptable. Others may discourage their male children from expressing pain [17]. 

Children and parents/guardians should always be reassured that it is normal for children to cry when something is painful. Children should never be shamed or made to feel guilty for crying or screaming. 

Pain Relief Strategies for Children 

In order to lessen pain and discomfort, the nurse should: 

• Encourage parental involvement: Include parents/guardians in pain control techniques and teach them their role in pain control for their child. Parents/guardians are the most important part of pain management.
• Use helpful devices: Consider using a device called “Buzzy” to decrease pain sensation during IV insertion or venipuncture [40]. This device combines cold and vibration to replace pain with movement and temperature. Research has shown this device effectively decreases pain and discomfort during some procedures [40]. 
• Encourage gaming: Provide these children with an outlet through virtual reality gaming. Virtual reality gaming has been shown to be highly effective as a distractor during painful procedures [28]. 
• Be honest: Be open and honest to children in their care. However, as aforementioned, consider what is in the best interest of the child when disclosing potentially distressing information to children. It may be beneficial to leave out certain details that would otherwise cause the child intense fear [16].  
• Provide distraction: Provide distraction for children to decrease their pain experience, such as play therapy, as mentioned above 
• Promote relaxation: Teach relaxation techniques to the child and parents/guardians, such as gently swaying a child, rocking, or having them take a deep breath, then relaxing their body on exhalation. 
• Promote guided imagery: Teach guided imagery to children and parents/guardians; examples include asking the child to verbalize relaxing experiences or having the child pre-tape their story of a relaxing event and listen to it during the painful procedure. 
• Promote positive self-talk: Encourage positive self-talk with the child. For example, having the child say, “I’m going to feel better soon” or “I know I can do this.” When self-talk statements conflict with the reality of the child’s situation or prognosis, a general rule of thumb is to always keep the child’s best interest in mind, as aforementioned [16] 
• Administer medications: Topical anesthetics can be used on any age child to decrease the pain sensation during IV insertion or venipuncture procedures. 

Pediatric Clients with Special Healthcare Needs 

According to the CDC, nearly 1 in 5 children in the U.S. has a special healthcare need [9]. The special needs pediatric population carries many complex health issues, such as emotional and mental health struggles that may be chronic and lifelong [9]. A child with special needs may have a physical, developmental, emotional, behavioral, or intellectual condition/disability that requires specialized care or interventions [9]. However, beneath all the tubes, devices, and special needs equipment, there is a child who is like many children without special needs. They are longing to be seen, to be heard, and to be accepted as they are. 

Some suggestions for nurses when caring for this population include [35]: 

• Feeding/Eating: Children with special needs may have trouble feeding or eating due to physical or psychological limitations (difficulty swallowing or digesting foods, inability to sit up to eat, taking a long time to feed themselves).  
• Sleep: Be patient with children with special needs, as they may have sleeping issues related to physical limitations (pain, breathing difficulties) or learning limitations (unsure when or why they need to sleep).  
• Elimination: While many children are potty trained by age 3, it’s important to understand that physical limitations (impaired mobility) and/or developmental limitations can cause some children with special needs to take a longer time learning to potty-train, if at all. Some remain permanently incontinent or have colostomies/ileostomies.  
• Mobility: Some children with special needs may use specialized care devices for mobility, communication, sleep, etc. (i.e., motorized wheelchairs or sleep apnea machines). Ensure these children can use their devices as needed during care. 
• Behavior: Be patient in understanding that children with learning or sensory limitations may have emotional outbursts or display challenging behavior as they struggle with expressing their needs. 
• Pain: Some children with special needs may have cognitive impairments, rendering them unable to communicate even by pointing out faces on the Wong-Baker Faces Pain Rating Scale. Consider using the “Non-communicating Children’s Pain Checklist,” which lists behaviors to assess in children aged 3 to 18 with cognitive or communication impairments [44]. Some children with special needs may make loud noises, but it may be hard to decipher if the vocalizations are pain-related. Asking the child’s parents/guardians/caregivers for help determining which of the child’s verbalizations indicate pain versus everyday vocalizations may help. 
• Family care: Be sure to care for the child’s parents/guardians/caregivers. Evidence shows the burden of care is much heavier in parents of children with special needs than in parents of children who have chronic diseases [27]. Resilience is also less common among parents of children with special needs. Make referrals as needed for support. 

Conclusion

The pediatric population requires nurses who embrace the cohesive bond between parents/guardians and the child. The nurse must work well with both to enhance the best care possible for the family. Advocacy takes on many forms as a pediatric nurse; the parent, the child, and the family unit must all be promoted and supported.

Nurses make a difference, and their care is multiplied with each client and hospitalization. Pediatric nurses, through dedication and mutual problem-solving with families, show responsiveness to children’s experiences, age, and development to meet the child in their world.