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The relationship between nursing and technology remains contested. This article debates whether technology--in particular the monitoring of cardiac function, oxygen saturation, respiratory rate, blood pressure and temperature--helps to provide better nursing care or whether it hinders nurses from developing their clinical assessment skills, and prevents them from providing humanistic and holistic care.

Children and young people with cancer often experience a diminished oral intake and exhibit subsequent weight loss and poor nutrition as a result of the side effects of treatments. This article studies the case of a five-year-old boy who developed nutritional problems to demonstrate the need for clear and systematic guidelines and protocols for nurses and health professionals to make uniform decisions in the management of such situations.

Aim: To review routine observations on all children admitted to the Children's Hospital for Wales and the feasibility of implementing an early warning score for children developing critical illness., Method: Nursing staff, while performing their routine duties, recorded the physiological observations of temperature, heart rate, respiratory rate and blood pressure, as well as identifying airway threat, recording oxygen saturation levels, level of consciousness using the AVPU scale (alert, responds to voice, responds to pain, unresponsive) and identifying if they had concerns about a child on a new paediatric observation chart. The clinical care policy for each ward determined the frequency of recording observations., Results: Data were collected for 1,000 patients on whom 9,075 sets of observations were performed. Of those 9,075 sets, temperature was the most frequently recorded observation at 88.4% (95% confidence interval (CI) 87.7-89), followed by heart rate at 86.8% (95% CI 86.1-87.5), respiratory rate at 79.7% (95% CI 78.9-80.5), AVPU at 36.4% (95% CI 35.4-37.4) and blood pressure at 25.1% (95% CI 24.2-26.0). A complete set of observations needed for the Cardiff and Vale Paediatric Early Warning System to trigger effectively were only recorded in 52.7% (95% CI 52.4-53.1) of patients., Conclusion: There were variations in the frequency, type and recording of observations. This issue needs to be addressed if scoring systems are to be implemented. The findings of this observational study suggest that the required basic observations of acutely ill children are not being carried out.

This article offers practical guidance on how to tackle homophobia in all settings for young people. It provides advice on tackling homophobic attitudes and bullying on several levels. The areas covered are: use of language and individual interactions, examining institutional policy and ethos, staff training, and holding workshops with young people.

Cardiovascular assessment is an important nursing skill in the assessment and management of acutely ill children and children with chronic conditions. This article outlines the differences in the cardiovascular systems of infants, children and adults, and explains how to provide circulatory assessment in children, focusing on assessing pulse and blood pressure.

Young people attracted to people of their own sex are at risk of bullying and discrimination. It is often difficult for them to find support. Either emotionally or in relation to their health needs. This article explores a model to aid nurses in understanding the process individuals go through before coming to terms with their sexuality. The model also outlines the steps that nurses can take to enhance the care they provide for this vulnerable group of patients and clients.

Almost 1,000 babies are born each year with some form of cleft, whether it is a palate, lip or a combination. However, with the advent of new regional cleft centres and specialist professionals caring for larger numbers of children with a cleft lip and palate, the long-term outcomes of these patients should show improvement. The nursing care on paediatric wards will make an important contribution to these outcomes. In this article, post-operative feeding, analgesia and inpatient stays following cleft palate repair are examined. In a post-palatoplasty study of 68 babies, 34 who were fed orally and 34 nasogastrically, the babies who were fed nasogastrically were more settled, needed less analgesia and were discharged earlier. The parents of these babies were more relaxed knowing their child was fed and had adequate analgesia, and nurses believed they were able to give these babies a better quality of care.

Primary ciliary dyskinesia is a rare inherited condition affecting the movement and structure of the cilia in various areas of the body, including sinuses, ears and airways. Since 2006, three centres for diagnosis and research in England have been raising awareness and funding for primary ciliary dyskinesia's diagnosis and treatment. Other areas in the UK have their own arrangements and can refer to one of the English centres. This article discusses the condition, introduces the centres and advises on where to get more information. The author concludes that paediatric nurses are in a unique position to learn about and increase awareness of the condition to help prevent unnecessary ear, nose and throat surgeries and permanent lung damage.

Evidence supports the use of superficial heating and cooling of tissues to provide pain relief in low to moderate levels of acute and chronic pain in adults, but there are no standards or guidelines in children's centres across the UK for administering these modalities in children, so a project was undertaken to develop these locally. Evidence from the literature was used to identify best practice in relation to equipment, safety and infection control. Implementation was supported by educational input and a detailed protocol for assessment and application of the devices. Three years after their introduction a review of the guidelines and an audit demonstrated that these modalities have been beneficial, providing cost-effective, holistic care for children experiencing pain in hospital.

Nurses and other carers of people with learning disabilities must be able to manage choking events and perform basic life support effectively. UK guidelines for assessment of airway obstruction and for resuscitation do not take account of the specific needs of people with profound multiple learning disability. For example, they fail to account for inhibited gag and coughing reflexes, limited body movements or chest deformity. There are no national guidelines to assist in clinical decisions and training for nurses and carers. Basic life support training for students of learning disability nursing at Birmingham City University is supplemented to address these issues. The authors ask whether such training should be provided for all nurses including those caring for children and young people. They also invite comment and discussion on questions related to chest compression and training in basic life support for a person in a seated position.

Children's rights, their ability to consent to treatment and their involvement in healthcare decisions have received considerable attention in recent years. There is some evidence to suggest that when children are involved in the decision-making process, they retain a sense of control over their situation. However there are still unresolved issues related to a child's right to decide and nurses may be confused about the extent to which children can and should be involved in decision-making. A code of practice for involving children in decisions was first suggested in 2001 and there is still a need for a consistent, structured and robust method of ensuring that children are included in the decision-making process at all stages of their health care.

The use of sedation and analgesia in critically ill children is necessary for clinical management but can result in undesirable side effects such as physical dependence, tolerance and withdrawal symptoms. Weaning from sedation aims to prevent such unpleasant effects. Regular scoring of signs and symptoms of withdrawal is an essential part of the weaning regime, allowing the clinician to assess whether reduced doses are causing withdrawal symptoms. However, there are wide variations in whether and how scoring systems are used. This variation may be the result of high workload, other external pressures, traditional ways of working or other factors. Strategies such as an easily accessible scoring flow chart, a poster display, improved staff induction or other measures could help to improve safety and quality in sedation management.

Central venous catheters (CVCs) are an essential tool in paediatric intensive care, providing a means to monitor patient haemodynamics and to administer fluids, nutrition, blood products and medications. Because multiple factors contribute to the high risk of catheter related infection, a multi-strategy approach is required to prevent such infections. Using contemporary literature and clinical audit findings a 'care bundle' was created for use within the PICU at Birmingham Children's Hospital. This care bundle groups together best practices in order to prevent catheter related bloodstream infection.

Small bowel transplantation is a recent innovation and thus a relatively new area of nursing practice. There is a lack of literature on the nursing care of children whose only hope of long-term survival is small bowel transplantation. The aim of this article is to raise awareness about intestinal transplantation in children using a case study to highlight the main nursing implications including: multidisciplinary team working, monitoring fluid balance, caring for immunosuppressed patients, monitoring for acute rejection and discharge preparation of the child and family.

Nasojejunal delivery of enteral feeds is a safe and effective alternative to parenteral nutrition in critically ill children in whom intra-gastric feeding is usually poorly tolerated. A guideline for bedside placement of nasojejunal tubes (NJTs) was developed by a mulit-disciplinary group. An audit of practice was carried out following implementation of the guideline. During the audit period 27 NJTs were successfully passed in 21 patients. The result of this innovation has been early initiation of nasojejunal feeding and an increase in bedside placement of NJTs within the PICU. Paediatric radiologists have reported a reduction in requests for NJT placement under X-ray screening and there has been a reduction in the use of medication and X-ray to place NJTs. Based on the audit data, 58 per cent of the children would have definitely or probably commenced parenteral nutrition had NJT placement and feeding been unsuccessful. The audit also demonstrated that 26 out of 27 nurses and doctors reported they found the guidelines easy or very easy to follow. Reducing variations in practice through the use of guidelines increases the frequency of jejunal feeding. This benefits critically ill patients by improving tolerance of enteral feeding for better nutritional outcomes.

Available evidence indicates deficits in the pain management of children with analgesic drugs used outside licensed boundaries, in situations where their pharmacokinetics are untested. A case series is used to demonstrate the effectiveness of more holistic techniques such as guided imagery and distraction therapy in reducing the pain experienced by children in the hospice setting. Using these techniques it may be possible to reduce the amount of analgesia or the frequency of administration.

Assessment is a major nursing role, and expanding assessment techniques, traditionally seen as the remit of the medical profession, can assist nursing assessment and the provision of appropriate care. This is the third article in a series of five articles. Parts 1 and 2a provided a practical critical review of the validity and reliability of basic respiratory assessment focusing on measurement of respiratory rate, rhythm and depth. This article provides a practical step-by-step introduction to the theory and practice of advanced respiratory assessment using palpation. Next month we will build on these skills and provide a practical step-by-step introduction to using auscultation in order to augment basic respiratory assessment skills.

As the focus on evidence-based healthcare delivery gains momentum, nurses need to critically reflect on their traditional practice base. Assessment is the cornerstone of safe and effective practice and goes hand in hand with the process of prioritising a sick child's needs. This article begins with a practical and critical review of the validity and reliability of basic respiratory assessment focused on measurement of respiratory rate, rhythm and depth. Part 2b in February 2007 will be a practical step-by-step introduction to the theory and practice of advanced respiratory assessment using palpation. Part 2c in the following month will focus on respiratory auscultation methods.

A positive incident during a placement in a special school is used to illustrate that reflecting on positive incidents helps the student nurse to recognise good practice and personal strengths. The incident involving a child's achievement in mastering new communication skills led to improved understanding of the role of the special educational needs teacher and the speech and language therapist and the positive effect of early professional intervention. It also emphasised the benefits of Makaton and picture aids for children with communication problems. A major benefit of the placement experience was that it improved the student's confidence in approaching and interacting with children with special needs and speech difficulties. It also highlighted the value of nurses learning basic Makaton in order to enhance their communication skills. Using reflection to review positive experiences can be as effective in highlighting strengths and weaknesses as reflecting upon negative experiences.

Insertion of nasogastric tubes is a common nursing procedure but practice rituals and unfounded assumptions can compromise safety. Current methods for checking the position of nasogastric tubes are not always suitable in children but there is limited guidance on how to proceed when gastric placement cannot be determined. As a result of a local adverse incident, a working party challenged the assumptions and rituals of practice using an evidence-based framework. A nasogastric tube algorithm was developed using a risk assessment approach to improve the safety of children in hospital and community settings.

Measurement of children's height and weight at regular intervals is important for identifying growth problems as well as for planning health promotion interventions for those at risk from under or over nutrition. Opportunistic measurement is recommended when children are seen by healthcare professionals for other reasons. Identification of variations in practice around measurement of height and weight in a children's unit led to the development of guidelines, purchase of new equipment, implementation of educational strategies and introduction of a growth link nurse role. Repeat audit revealed that these approaches did not bring about the desired changes in practice. Growth assessment is a quick, non invasive procedure that can provide valuable information about the general health and well being of the child but is perceived as a low priority by some healthcare professionals. Different approaches are needed to improve this important aspect of health care for children.

An audit to evaluate a protocol for the management of children and young people presenting with self-harm was undertaken at Calderdale and Huddersfield NHS Trust. The objectives were to review current practice and to identify strengths and challenges. The audit showed that most staff were aware of the written procedure for obtaining a specialist assessment by the child and adolescent mental health services (CAMHS), but that feedback was inconsistent and there was a need for improved communication between health professionals.

Many health professionals seem to lack the knowledge and skills required to understand and communicate with the child or young person with an autistic spectrum disorder. Educational materials about this subject for student nurses and healthcare professionals were developed as part of a nursing course and are presented in this article as an introductory reference for those seeking to improve their communication with these children. A short resource list is provided.

The accurate diagnosis of urinary tract infection (UTI) in young children is important for initial management and the prevention of long-term damage to the developing kidney. Various methods are used for urine collection from the non-potty-trained age group, including catheterisation, suprapubic aspiration, clean-catch sampling, adhesive bag sampling and urine collection pads. Research literature was examined to identify which method is most effective. The themes that evolved from the review were parents' and nurses' views on ease of use, reliability of sample obtained and cost-effectiveness. Although not the most convenient method, clean-catch gives more reliable results making it also the most cost effective approach. Change management strategies are required to overcome barriers to research implementation and to ensure best practice.

Even though care of children with tracheostomies may differ between hospitals, there are basic principles and procedures that all nurses should be aware of including how to respond in an emergency.

Nurses are well placed to identify behaviour or circumstances that might signify a child is at risk and to contribute to measures designed to protect children. Legislation, guidance and local policies provide the framework for nurses to implement good practice in communication, documentation and multi-agency working to safeguard every child and young person with whom they have contact.