Nursing Process in Paediatric Nursing
The paediatric nursing process is a systematic, child- and family-centred method of assessment, nursing diagnosis, planning, implementation and evaluation used to provide safe individualized care. It is continuous: every intervention is followed by reassessment, documentation and revision of the care plan.
Objectives
- Explain the five stages of the nursing process and their interrelationship.
- Perform an age-appropriate comprehensive paediatric assessment.
- Formulate prioritized nursing diagnoses, measurable outcomes and rational interventions.
- Evaluate response, recognize deterioration and communicate safely with caregivers and the health team.
Principles Unique to Children
- Age and development: normal observations, communication, fears, play and self-care capacity change with age.
- Family partnership: caregivers supply history and comfort, but the child remains the primary patient.
- Rapid deterioration: airway, breathing, circulation, disability and exposure (ABCDE) take priority over routine paperwork.
- Weight-based care: all medicine, fluid and equipment decisions use an accurate current weight in kilograms.
- Growth and prevention: every encounter is an opportunity to review nutrition, growth, immunization, development and safety.
- Safeguarding: inconsistencies, delay in seeking care, injuries of different ages, neglect or fearful behaviour require sensitive assessment and reporting through policy.
Stage 1: Assessment
A. Immediate rapid assessment
- Airway: listen for stridor, snoring or silence; observe secretions, swelling and ability to vocalize.A child’s narrow airway can obstruct rapidly. Open and support the airway while calling for help.
- Breathing: count respiratory rate for a full minute where appropriate; observe recession, grunting, nasal flaring, head nodding, cyanosis and oxygen saturation.Work of breathing and mental state may show severity before saturation falls.
- Circulation: pulse, capillary refill, skin temperature/colour, blood pressure where equipment is correct size, bleeding and urine output.Tachycardia and poor perfusion often precede hypotension; hypotension is a late sign of paediatric shock.
- Disability: Alert/Voice/Pain/Unresponsive level, pupils, seizures, tone and bedside glucose in an ill or altered child.
- Exposure: temperature, rash, oedema, injuries, dehydration and complete examination while preventing heat loss and preserving dignity.
IMCI general danger signs: inability to drink or breastfeed, vomiting everything, convulsions, and lethargy or unconsciousness. Severe respiratory distress or other critical signs also demand immediate action.
B. Comprehensive history
| Area | What to assess | Clinical significance |
|---|---|---|
| Presenting problem | Onset, sequence, severity, exposures, treatment already given and effect. | Builds the clinical timeline and identifies deterioration or medication errors. |
| Pregnancy/birth | Gestation, maternal illness/medicines, place/mode of birth, cry/resuscitation, birth weight and neonatal problems. | Prematurity, asphyxia and infection influence current risk and development. |
| Feeding/nutrition | Breastfeeding, complementary diet, appetite, vomiting, stool, food access and feeding technique. | Detects dehydration, malnutrition, aspiration and food insecurity. |
| Growth/development | Growth chart trend, milestones, school progress, hearing/vision and regression. | Regression or faltering growth may signal serious neurological, chronic or social disease. |
| Immunization | Verify card, doses due/missed, contraindications and adverse-event history. | Prevents missed opportunities and helps differential diagnosis. |
| Past/family history | Admissions, surgery, transfusion, allergy, chronic illness, sickle cell disease, TB/HIV exposure and hereditary disease. | Shapes investigation, isolation, medicine and discharge plans. |
| Medicine history | Prescription, over-the-counter, herbal medicines, exact concentration/dose/time and adherence. | Children are vulnerable to dosing and formulation errors. |
| Social/safety | Caregiver, housing, water, smoke exposure, sleeping, transport, finances, school, violence and safeguarding. | Determines feasibility of care and hidden risks. |
C. Physical examination
- Observe before touching: appearance, interaction, posture, colour, breathing, cry, movement and caregiver-child relationship.
- Use least upsetting steps first; examine throat/ears and other distressing areas later when safe.
- Measure temperature, pulse, respiratory rate, SpO2, BP where indicated, weight, length/height, head circumference in young children and MUAC where applicable.
- Interpret all measurements against age, clinical state and trends; one normal value does not exclude serious illness.
- Perform head-to-toe examination, pain assessment and developmental observation.
Stage 2: Nursing Diagnosis
A nursing diagnosis describes the child’s response or risk that nursing can address. It is not merely the medical diagnosis. A problem-focused statement commonly includes problem + related cause + supporting evidence; a risk diagnosis states the risk and contributing factors without invented symptoms.
| Medical situation | Possible nursing diagnosis | Evidence/risk factors |
|---|---|---|
| Pneumonia | Ineffective breathing pattern | Tachypnoea, recession, grunting and fatigue. |
| Acute diarrhoea | Deficient fluid volume | Reduced intake, frequent stool, dry mouth, poor perfusion and reduced urine. |
| Malnutrition | Imbalanced nutrition: less than body requirements | Faltering weight, wasting, poor intake and feeding difficulty. |
| Hospitalization | Anxiety/fear | Crying, withdrawal, separation and unfamiliar procedures. |
| IV therapy | Risk for infection | Break in skin barrier, young age and invasive device. |
| Chronic illness | Caregiver role strain/deficient knowledge | Complex regimen, fatigue, financial barriers or inaccurate technique. |
Prioritization
- Actual or threatened airway, breathing and circulation problems.
- Neurological deterioration, seizures, hypoglycaemia and severe pain.
- Fluid/electrolyte, temperature, infection and nutrition threats.
- Safety, skin, elimination, mobility, sleep and developmental needs.
- Education, coping, discharge and long-term prevention.
Stage 3: Planning and Expected Outcomes
Goals should be specific, measurable, achievable, relevant and time-bound. State the desired child/family response, not simply the nursing activity.
| Weak goal | Improved measurable outcome |
|---|---|
| Child will breathe better. | Within one hour, work of breathing will reduce, SpO2 will remain within the prescribed target and the child will show no cyanosis or exhaustion. |
| Improve hydration. | During the shift, perfusion and mental state will improve, oral/IV replacement will meet the prescribed plan, and urine output and losses will be measured. |
| Mother will understand medicines. | Before discharge, caregiver will correctly demonstrate dose measurement, state schedule/duration and identify three urgent return signs. |
The plan identifies observations and frequency, prescribed and independent interventions, caregiver participation, needed equipment/referrals, education and escalation thresholds.
Stage 4: Implementation
Safe interventions with rationales
| No. | Action | Rationale |
|---|---|---|
| 1 | Identify child with two identifiers and confirm current kilogram weight. | Prevents wrong-patient and weight-based dose/fluid errors. |
| 2 | Explain care using age-appropriate language; involve caregiver and obtain consent/assent. | Reduces fear, supports rights and improves cooperation. |
| 3 | Perform hand hygiene and use transmission-based precautions when indicated. | Reduces healthcare-associated infection. |
| 4 | Administer medicines using rights of medication administration; calculate mg/kg and maximum dose independently. | Paediatric concentrations and decimal errors can cause severe toxicity. |
| 5 | Measure all intake and losses; use accurate devices and infusion control. | Small absolute errors can be clinically significant in infants. |
| 6 | Provide atraumatic care: comfort positioning, pain relief, distraction and clustered procedures. | Reduces pain, fear and physiological stress. |
| 7 | Support feeding, warmth, sleep, play and developmental stimulation. | Hospital care must preserve growth and development, not only treat disease. |
| 8 | Escalate deterioration using a structured handover such as SBAR. | Clear urgency, findings, actions and response reduce treatment delay. |
Paediatric medicine calculation safeguards
- Write kilograms explicitly; never calculate from pounds without verified conversion.
- Calculate prescribed dose: dose per kg × current weight, then compare with the maximum and recommended range.
- Calculate volume from the actual bottle/ampoule concentration; avoid trailing zeros and use a leading zero for values below one.
- Use an oral syringe for small liquid doses, not a household spoon.
- Independently double-check high-alert drugs, insulin, opioids, concentrated electrolytes and chemotherapy.
Stage 5: Evaluation
- Reassess at the expected time: observations, pain, perfusion, breathing, intake/output, mental state and disease-specific findings.
- Compare with the stated outcome: achieved, partially achieved or not achieved.
- Explain non-response: wrong diagnosis, progression, inadequate dose, poor delivery, complication, caregiver barrier or new problem.
- Revise and escalate: continue effective measures, modify the plan within authority and urgently report deterioration.
- Document: time, objective findings, interventions, response, communication and new plan.
Complete Example: Child With Acute Diarrhoea
| Process stage | Application |
|---|---|
| Assessment | Danger signs; stool/vomit frequency; drinking; thirst; eyes, mouth, skin pinch and perfusion; weight; urine; fever/blood in stool; feeding and home fluids. |
| Diagnosis | Deficient fluid volume related to GI losses, evidenced by clinical dehydration; risk for electrolyte imbalance; deficient caregiver knowledge where demonstrated. |
| Outcome | Child will complete the prescribed rehydration plan, show improving hydration/perfusion and tolerate continued feeding without deterioration. |
| Implementation | Give ORS in frequent measured amounts according to classification; continue breastfeeding; replace ongoing losses; administer zinc and other prescribed treatment; record input/output; teach caregiver. |
| Evaluation | Reassess hydration, weight where indicated, urine, drinking and vomiting; escalate shock, inability to drink, persistent vomiting, blood in stool or worsening consciousness. |
Discharge Planning
- Confirm stability, feeding, caregiver competence and safe transport/home circumstances.
- Provide written and verbal medicine instructions using teach-back.
- Give precise return signs: difficulty breathing, convulsions, inability to drink/breastfeed, repeated vomiting, abnormal sleepiness, worsening fever, reduced urine or caregiver concern.
- Review immunization, nutrition, growth, development, follow-up date and referral completion.
- Document handover and ensure caregiver knows where to return day or night.
Common Errors
- Copying an adult care plan without age adaptation.
- Writing a medical diagnosis as the only nursing diagnosis.
- Listing routine interventions without rationale, frequency or evaluation criteria.
- Ignoring caregiver knowledge and feasibility of home treatment.
- Completing documentation while delaying emergency stabilization.
- Recording “stable” without objective observations and trend.
Revision Questions
- Describe the five stages of the nursing process using one paediatric condition.
- Explain why paediatric assessment begins with observation and ABCDE.
- Formulate three nursing diagnoses and measurable outcomes for a child with pneumonia.
- Outline safeguards for weight-based medicine administration.
- Explain how evaluation changes the care plan.