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Assessing unwell children: advice for nurses

Young children frequently become unwell, and whether or not it is part of your role to manage ill children, many groups of nurses working in primary care will see them in the context of their work. Wendy Johnson explains how to assess unwell children

Wendy Johnson
MSc BSc(Hons) RN DipN(Lond) NPDip PGCIE
Advanced Nurse Practitioner in Primary Care and Senior Lecturer
Nurse Practitioner Programme
London South Bank University

Small children have four to six acute illnesses per year, most commonly viral upper respiratory tract infections (URTI), most of which are trivial and self-resolving. However, it is vital to be able to distinguish children who are really ill from those who are simply mildly unwell, and to know when to act or when a further opinion should be sought.
Conditions can change very rapidly. A seemingly minor ailment can within hours escalate into serious compromise from a life-threatening illness. Awareness of the range of common childhood presentations and how to distinguish benign from more serious conditions is an essential skill for safe practice.
This article is intended to highlight some of the issues to be considered when dealing with unwell children. It is not intended to replace formal learning and supervised clinical practice. The Royal College of Paediatrics and Child Health make it clear that all front-line staff delivering urgent care to children must be competent in the basic skills required for safe practice, in whichever setting they work.(1) It is strongly advised that all nurses undertaking this often complex and risky work should practise under supervision, and always have ready access to support and advice.

What makes children different?
Children are not "little adults". They exhibit important anatomical and physiological differences when compared with adults. These include a greater surface area-to-weight ratio and higher water content, particularly in infants, who also have an increased metabolic rate and risk of fluid loss, with a limited ability to concentrate and dilute urine. The skin is thin and easily permeable, allowing heat and water loss. Components of the small respiratory system are in close proximity, allowing more ready transmission of infection, and the narrow lumen airways become easily obstructed when inflamed. The shorter eustachian tube allows infection to pass more readily from the pharynx, due to its close proximity, while the small intestine is significantly longer, and when inflamed can lose much more fluid than an adult. In addition, infants have poor temperature control. Those under three months of age are less able to localise and mount an immune response, and have low levels of some immunoglobulins, making them at greater risk of overwhelming infection.   
The range of illnesses that children suffer from have a developmental component.(2) For example, bronchiolitis is seen in the under-ones, while otitis media is common in under-threes.
Atypical presentations and nonspecific signs of illness are common, especially in the very young (see Box 1). Urinary tract infection (UTI) in small children rarely presents with the typical dysuria and frequency seen in adults. Pneumonia may present simply as abdominal pain without typical chest symptoms. The early stages of meningococcal disease are very similar to minor viral illness, and diagnosis is very difficult; up to 50% of children with meningococcal disease presenting to primary care are not initially recognised, often because they present early with nonspecific symptoms and signs.(3)
Assessment therefore needs to be systematic and very thorough, and must exclude "red flags" (see Box 2). 
Examination findings vary with age, and some typical physical signs may be absent in young children, eg, neck stiffness in meningitis and typical chest signs in pneumonia.

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Response to illness
Children often become ill very quickly, but can also make a rapid recovery. However, they sometimes compensate well until late in an illness, then rapidly collapse.

Family and social context
The child is not the only focus of care and needs to be considered in family context. This includes factors such as parental confidence and coping, the social situation, and any other siblings.

Assessment 
The basic principles of a safe and effective assessment of a young child are the same regardless of the presentation. It is vital to approach the assessment in a careful and methodical manner, in order to detect serious or progressive signs, and rule out "red flags" (see Box 2). The aim is to avoid missing pathology, which may have a serious and devastating effect on the child. The primary objective is for accurate diagnosis, and to distinguish those children who can be easily managed in primary care, from the more seriously ill child who needs referral and aggressive treatment.(4)

History
Any assessment starts with a thorough history. As a child's history is almost always given by a third person, it may be less accurate than when obtained direct from the patient. If the child is old enough, try to obtain information from them too. In addition to the usual components of a health history, specific paediatric considerations include who the child is with and the accuracy of the information given; a parent bringing a child who has spent the day in nursery, or with another carer, may not have an accurate picture of the child's recent behaviour. It is important to listen to the concerns of parents, as they know their own child well.(5)
Key features of the history include the child's general behaviour - are they alert, playing normally, eating and drinking as usual, and producing the usual amount of urine? These are all important features of a well child. In addition to details of the presenting complaint, birth and neonatal history, any past medical history, immunisation status, and exposures to infectious diseases, including travel-related illness should be included. Ask about any treatments tried so far and their effect: be aware that fever cannot be excluded in a child who has received antipyretic in the past four to six hours.

Examination
Because of the limitations of history, physical examination assumes even greater important when assessing a child. General behaviour and physiological parameters are important indicators of wellbeing, and must be carefully and accurately recorded. Vital signs (measured when the child is calm, and checked against age-appropriate norms, see Table 1),
capillary refill time, and oxygen saturation (if available) all contribute to the overall assessment. A top-to-toe examination is mandatory, but the order in which it is done should be opportunistic, always leaving traumatic procedures such as inspecting the throat until last. The child needs to be undressed so that careful observation can be made.
Examination includes:

  • General behaviour: look at the child, does he look normal, lively, alert and interested in his surroundings, or is he lethargic or restless? Observe his reaction to his carer, is he making eye contact, or taking a feed?
  • Skin, observe for colour, perfusion, rashes and lesions. Check for hydration by feeling skin turgor and moisture of the mouth mucous membranes.
  • Airway and breathing: listen for noisy breathing or stridor; look for drooling (signs of upper airway obstruction); and observe the chest and effort of breathing. Are accessory muscles being used? Check for intercostal or subcostal recession (indrawing of the soft tissue between or under the ribs) and chest shape. Auscultate listening for air entry throughout, breath sounds and any added sounds such as wheezes and crackles. Auscultation has limited accuracy in younger children as typical findings may be absent in infection, and "transmitted sounds" from a blocked nose in a URTI may be confused with focal signs. 
  • Circulation can be assessed by observing and feeling peripheries for colour and temperature, measuring capillary refill time and heart rate. 
  • Abdomen should be auscultated for bowel sounds and palpated for softness and lack of tenderness.
  • Always consider checking dipstick urinalysis in an unwell child, as urinary tract infection is a common non-specific presentation, which can be easily missed.(6)

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Management
Management depends on diagnosis. There are now national guidelines for most common conditions: the new NICE guidance on Feverish Illness in Children is a valuable resource, as are the "Clinical Knowledge Summaries" for a whole range of minor illness.(6,7) Clear and specific evidence-based written information should be given to parents, and a careful "safety net" of verbal and/or written information on warning symptoms and how further healthcare can be accessed, completes a safe consultation.

Conclusion
Assessing unwell children is a frequent yet complex and calculated task. A rapid, but thorough and systematic assessment of all unwell children is vital because of the nonspecific nature of many presentations. All nurses dealing with unwell children need an awareness of what makes them different from adults, the types of illness they suffer, and how to approach the assessment. Access to support, advice and rapid referral as appropriate is vital.

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References

  1. Royal College of  Paediatrics and Child Health. Services for children in emergency departments. London: RCPCH; 2007. Available from: http://www.rcpch.ac.uk 
  2. Barnes K. Paediatrics a clinical guide for nurse practitioners. London: Butterworth Heinemann; 2004.
  3. Thompson M, et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006;367:397-403.
  4. Davies F and Department of Health. Spotting the sick child DVD. 2004. Available from: http://www.ocbmedia.com
  5. Gill D, O'Brien N. Paediatric clinical examination made easy. 5th ed. Oxford: Churchill Livingstone; 2006.
  6. NICE. Feverish illness in children. London: NICE; 2007. Available from: http://www.nice.org.uk
  7. Clinical Knowledge Summaries. Available from:http://www.cks.library.nhs.uk


Resources

Several universities now run short courses on children's illness for the nonpaediatric trained nurse, eg, London South Bank University have an "Assessment of Management of Children's Minor Illness in Primary Care Settings" module.