Exam 11, Care of the Pediatric Patient 1
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| Growth | Viewed as quantitative change
Increase in number and size of cells
Results in increased size and weight
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| Development | Gradual change and expansion as the whole from lower to more complex stages of an individual’s capacities through growth, maturation and learning
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| Maturation | An increase in competence and adaptability
Aging
Ability to function at higher level
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| Differentiation | Processes by which early cells and structures are systematically modified and altered to achieve specific characteristics
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| Growth Trends; 3 phases of Directional | 1: Head to tail
2:promimodistal
3: Differental
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| Sequential |
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| Developmental Pace |
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| Sensitive Periods |
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| Individual Differences |
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| _______ is the most prominent feature of the childhood and adolescence. | physical growth
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| Both_____ and ______ are used indicatorsof development. | bone age
dentition
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| when are the two dramatic periods of rapid brain growth? | 15-20 weeks
30weeks-1yr
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| the basal caloric requirment for infants is about ____kcal/kg of body weight. This amount decreases to somewhere between___ and ___ kcal/kg at maturity. | 108
40
45
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| what are the 9 identified charactorists of temperament? |
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| What is the age range that a child can take an oral temp? | gretaer then 2 years-5years.
when they can hold probe in mouth.
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| What is reccomended temp route for the age birth- 2years | AX or Rectal temp
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| How long should you count a pulse rate on an infant and young children? | 1 full minute
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| What is the most reliable measurement of pulse taken? | apical pulse
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| While measuring respirations in the infant do you watch the abdomen or the chest? why? | abdomen, infants are belly breathers.
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| BP should be measured annually in children over the age of ? | 3 years old
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| the most important factor in accurately measuring BP is the use of _____ ____ _____. | appropriate size cuff.
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| Freud Define Id, ego, and super ego. |
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| Erikson |
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| Piaget best known theorist for children | Intuitive
Concrete operational
Formal operations
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| : How does growth and development impact nursing care of children? | : Approach to care, response to illness, application of nursing process, expected development, individual temperament, and intervention to prevent diseases and/or accidents.
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| What factors influence the formation of a child’s self esteem? | Temperament and personality, ability to accomplish age appropriate tasks, significant others, and social roles and expectations.
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| Self esteeem is at the most risk to which age population? | Adolesence
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| 4 factors that influence the formation of a childs self esteem. | 1.Temperament and personality
2.Ability to accomplish age appropriate tasks
3.significant others
4.social roles and expectations
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| Name four major stressors of hospitalized children. | Separation anxiety
Loss of control
Bodily injury
Pain
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| Name five nursing considerations for the hospitalized child to help manage stress. | Sensitivity/
Parents room-in;/ participate care
Staff continuity/
Freedom of movement;/ independence/
Articles from home
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| Name two pain rating scales for infants and two for children. | NIPS-neonatal infant pain scale
PRS-pain rating scale
FACES pain rating scale-Wong and Baker
Numeric Scale (one to 10)
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| What are some non-pharmacologic pain management techniques? | Distraction, relaxation, guided imagery, cutaneous stimulation, thought stopping, positive self-talk
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| Explain the purpose of dramatic play. | Allows child to emotionally release by reenacting frightening or confusing hospital experience; also allows child to learn about new procedures and what to expect prior to experiencing them first-hand
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| Why is it important for nurses to be culturally competent? | It is important for nurses to be culturally competent in order to deal effectively with families in a multicultural community or a community that is different from one’s own.
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| Respiratory infections account for majority of acute illness, these include: | Viruses
Bacteria
Fungal
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| Respiratory Sounds | Cough
Hoarseness
Grunting
Stridor
Wheezing
Crackles
Absence of breath sounds
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| Observe Ped For patient for: | Evidence of infection
Cough
Wheeze
Cyanosis
Chest pain
Nasal mucus
Halitosis
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| The lower respiratory tract includes? | The lower trachea, main stem bronchi, segmental bronchi, subsegmental bronchioles, terminal bronchioles and the alveoli.
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| Acute Pharyngitis | Inflammation of structures of throat/
80-90% caused by virus/
Throat culture – GABHS
GABHS risks
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| Therapeutic Management GABHS | Penicillin
Erythromycin if PCN allergic
Antipyretics
Push fluids
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| What is another name for nasopharyngitis? | The common cold.
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| Why aren't antibiotics given for nasopharyngitis? | Antibiotics are for bacteria and the common cold is caused by a virus.
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| Therapeutic Management for STREP | Self-limiting and symptomatic—viral
Antibiotics for + bacteria (Strep)
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| why would a PT have an Adenoidectomy | Adenoiditis-recurrent
Sinusitis-recurrent
Otitis media w/ effusion- recurrent
Airway obstruction w/ sleep-disordered breathing
Rhinorrhea-recurrent
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| why would a PT have a Tonsillectomy | Malignancy
Peritonsillar abscess (medical emergency) recurrent
Airway obstruction
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| : What post-operative complication requires immediate medical attention, above all others? | Hemorrhage.
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| Croup Syndromes | Generalized term
Hoarseness
Resonant “barking” or “brassy” cough
Varying degrees of respiratory distress
originates from Larynx
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| Acute Epiglottis | Serious obstructive inflammatory process
2-8 year olds
Requires immediate attention
Red Cherry appearance of epiglottis
Rapid progression to respiratory distress
Appears sicker than clinical findings suggest
Drooling
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| Acute Laryngotracheobronchitis | Most common “croup” syndrome
Parainfluenza
RSV
M. pneumoniae
Usually preceded by URI
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| Therapeutic Management for Acute Laryngotracheobronchitis | Maintain airway
Provide adequate respiratory exchange
High humidity
Racemic epi
steroids
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| Acute Spasmodic Laryngitis | “midnight croup” or “twilight croup”
Paroxysmal attacks of laryngeal obstruction
Most cases typically ***NO Fever****
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| Bacterial Tracheitis | Features of croup and epiglottitis
Serious cause of airway obstruction
Many organisms may cause Thick, purulent tracheal secretions—prominent feature
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| Bacterial Tracheitis, may have the symtoms of LTB(Laryngotracheobronchitis) but is UNRESPONSIVE to treatment. True or False? | TRUE
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| Therapeutic Management for Bacterial Tracheitis | VIGOROUS USE OF ANTIBIOTICS
ENDOTRACHEAL INTUBATION MECHANICAL VENTILATION
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| Which form of croup can develop into a respiratory emergency? | : Acute croup (laryngotracheobronchitis)
~LTB~
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| Respiratory Syncytial Virus (RSV) | Bronchiolitis is acute viral disease
Main cause of hospitalization in <1 year old
RSV infection main cause
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| Transmission of Respiratory Syncytial Virus (RSV) | Contact respiratory secretions
RSV easily spread
Survive for more
than 6 hours on counters, tissues soap
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| Clinical Manifestations Respiratory Syncytial Virus (RSV) | URI
Runny nose
Low grade fever
Ear infection / conjunctivitis
Cough
If disease progresses becomes a lower airway infection
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| Lower Airway Manifestations Respiratory Syncytial Virus (RSV) | Altered air exchange
Wheezing
Retractions
Crackles
Dyspnea
Diminished breath sounds
Apnea—may be the first recognized indicator of RSV in very young infant
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| Therapeutic Management of Respiratory Syncytial Virus (RSV) | Humidifier,hydration,suction,Airway maintenance
Ribavirin(Antiviral)
Synagis(man-made antibody to respiratory syncytial virus)
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| Nursing Care for Respiratory Syncytial Virus (RSV) | Isolation
Limit caregivers
Educate on suctioning procedures
Monitor oxygenation
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| How long can RSV (Respiratory Syncytial Virus) survive on countertops, tissues and soap bars? | More than 6 HOURS.
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| Pneumonia types | Lobar
Bronchopneumonia
Interstitial
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| Etiologic Agents of pneumonia | Viral
Bacterial
Mycoplasmal
Aspiration
Fungal
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| How is pneumonia classified? | Morphologic, but most useful is based on the etiologic agent.
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| Etiology of pneumonia | Allergy influences
Atopy
Triggers
Viral respiratory infections
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| _________ is a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness of breath, chest tightness, and coughing. | Asthma
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| Diagnostic Evaluation for Astma | •Recurrent wheezing
•Coughing
•Trouble breathing
•Chest tightness
•Symptoms that occur or worsen at night
•Symptoms that are triggered by cold air, exercise or exposure to allergens.
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| Pulmonary chronic airway obstruction due to astma can lead to______. | scarring
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| What are the classic signs of asthma? | Dyspnea, wheezing, coughing
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| What are the goals of asthma therapy? | Maintain normal activity, pulmonary function, prevent chronic symptoms, exacerbations, drug therapy, normal and happy child
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| Cystic Fibrosis | causes thick, sticky mucus to build up in the lungs, blocks the ducts of the pancreas affecting the digestive tract, and other areas of the body.Common chronic lung diseases
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| What are the two main problems related to the GI system as seen in Cystic Fibrosis? | : intestinal obstruction and prolapsed rectum
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| What exercises can the parents be taught to do at home to help move secretions up and out? | Postural drainage and chest physical therapy.
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| Astma Pathology | -Inflammation
-Bronchial constriction
-Decreased airflow
-Air trapping
-Hypoxemia
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| Name 4 types of parent teaching for Astma | Maintain health/home meds
S/S of broncho spasms
Avoid allergens
promote normal activities
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| Cerebral Dysfunction | Most brain status obtain by indirect measurements/
Newborn health and brain status/
Intellectual disability/
Hypoxic injury/
Developmental milestones/
Level of consciousness (LOC)
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| Increased Intracranial Pressure (ICP) | Any increase in the three components increasing total volume to > 100%
80% brain/
10% cerebrospinal fluid (CSF)/
10% blood
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| Body compensates to keep total volumes equal to 100% by doing what? | Reducing blood volume
/
Decreasing CSF production/
Increasing CSF absorption/
Brain mass shrinkage/
Open fontanels allow skull expansion and widened sutures/
At any age capacity for spatial compensation is limited
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| S/S of ICP | High-pitched cry
Headache/
Nausea, vomiting/
Seizures/
Bradycardia/
Decreased motor response to commands, painful stimuli/
coma/
If left untreated, death occurs
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| Alertness | an arousal-waking state, includes ability to respond to stimuli
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| Cognitive | power—the ability to process stimuli and produce verbal and motor responses
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| power—the ability to process stimuli and produce verbal and motor responses | Score 15—unaltered LOC
Score =< 8—coma
Score 3—deep coma
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| : What is the Glasgow Coma Scale used for? | It provides an objective measurement of levels of consciousness.
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| Explain what decerebrate positioning is and what it indicates. | Decerebrate positioning is a sign of dysfunction at the midbrain characterized by rigid extension and pronation of the arms and legs.
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| What signs of pain would you expect an unconscious child to display? | Signs of pain include the following: Changes in behavior (increased irritability and rigidity); Changes in physiologic parameters such as increased heart rate, increased respiratory rate and blood pressure.
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| Three major causes of Infant and toddler heads injuries. | #1 cause—Falls
#2 cause—<2 Motor vehicle injuries >2 pedestrian/cyclist injuries
#3 cause—bicycle injuries (esp 5-19 years old)
Boys > 2x girls due to risk-taking
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| Types of Head Injury | Concussion/Contusions and Lacerations/Fractures (fx)/Edema
/Hemorrhage/Diastatic/Open/Basilar/Comminuted/
Depressed/Linear
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| Name three problems caused by near-drowning. | Hypoxia, asphyxiation and hypothermia.
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| For a child admitted with near- drowning, what is the priority nursing consideration? | Respiratory support with attention to vital signs
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| : What are the most common signs and symptoms of a child with a brain tumor? | A child with a brain tumor is 4 hours postop. There is a small amount of clear drainage noted on her dressing. What do you suspect it is and what is the most appropriate thing for you, the LPN to do immediately
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| : What is the most common way that hydrocephalus is diagnosed in infants? | Based on head circumference that crosses one or more gridlines on the growth chart within a period of 2 to 4 weeks.
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| What are the signs and symptoms of infection in a child that is 24 hours postoperative shunt revision? | The signs and symptoms include: elevated vital signs, poor feeding, vomiting, decreased responsiveness, and seizures.
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| What defects cause hearing loss? | Defect in sound transmission, damage to nerve pathways or a mixture of both.
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| What are some methods of communicating with a hearing-impaired child? | Visual aids, writing, drawing and sign language.
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| Three most common bacteria with Otis media | Streptococcus pneumonia
Haemophilus influenza
Moraxella catarrhalis
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| Acute Otitis Media (AOM) vs Otitis Media with Effusion (OME) | TM purulent
Bulging, full, opacified, erythematous, nonmobile
Immobile TM always indicates at least OME, other symptoms make it AOM
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| Clinical Symptoms AOM | Otalgia acute onset
Fever
Purulent discharge (otorrhea)
Crying, irritability, restlessness, difficulty comforting child
Holding, rubbing, pulling on affected ear
Loss of appetite
Lethargy
OM may progress to hearing loss, difficulty communic
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| Therapeutic Management for AOM | Antibiotics:
First line - amoxicillin (high dose)
Second line
Ceftriaxone injectable
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| What are common signs and symptoms of otitis media? | Common s/s include pulling on the affected ear, irritability, fever, loss of appetite and purulent discharge.
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| To inspect the ear canal in an older child, what is the proper method of pulling the pinna? | : Up and back.
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| What are the most common types of visual disorders in children? | : Refractive disorders:
Myopia—nearsightedness
Hyperopia—farsightedness
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| Testing Visual Acuity | Several tests available assessing vision
Ocular Alignment
Visual Acuity
Peripheral Vision
Color Vision
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| binocularity | Object fixation by 3-4 months of age
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| strabismus | Want to detect any nonbinocular vision
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| amblyopia “Lazy eye” |
Blindness can occur due to suppression of image from lazy eye
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| Ocular Alignment Tests/Corneal light test – Hirschberg Test – | shine light from about 16 inches away into both eyes and check if light falls symmetrically within each pupil (normal)
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| Ocular Cover test | one eye is covered, look for movement of the uncovered eye while child looks at near or far object (no movement is normal)
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| Visual Acuity | Snellen Eye (Letter) Chart
Tumbling E eye chart
HOTV eye chart
Allen card test
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| Color Vision/Two types | Protanomaly-confusion gray: pink or pale blue: green
Deuteranomaly-confusion gray: pale purple or green
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| When should vision screening first be performed? | At the earliest possible age and at regular intervals.
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| Visual Refractive Errors | Myopia
Hyperopia
Astigmatism
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| Amblyopia (lazy eye) | Reduced visual acuity in one eye
Not treated may lead to vision loss in eye
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| Question: True or False The goal of medical interventions of one with strabismus is to return the eyes to normal functioning and position. | Answer: false
There is no treatment that will perfectly align the eyes. The goal therefore is to realign them as close to normal as possible.
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| Question: What nursing responsibility is common to all three of these eye disorders? | Answer: Early detection of signs and symptoms and referrals.
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| Retinoblastoma | Most common congenital malignant intraocular tumor or childhood
Arises from retina and mutation in gene
Can be inherited or sporadic
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| Leukokoria | Leukocoria literally means "white pupil." It occurs when the pupil (the round hole in the colored part of the eye) is white rather than the usual black
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| Question: What is Retinoblastoma? | Answer: The most common congenital malignant intraocular tumor of childhood.
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| Autism Spectrum Disorders | Neurodevelopmental disorders of brain function accompanied by intellectual and social behavioral deficits
Autistic disorder
Asperger syndrome
Pervasive developmental delay
Impairment mild to severe
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| What is Autism? | A developmental disorder of brain function.
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| Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension I | Intellectual functioning and adaptive skills
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| Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension II | Psychological and emotional considerations
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| Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension III | Physical, health, and etiology considerations
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| Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension IV | Environmental considerations
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| Cognitive Impairments | CI encompasses any type of mental difficulty or deficiency
Other terms, used interchangeably-Intellectual Disability; Mental Retardation
Definition-consists of three components
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| Classification of Cognitive Impairments Educable mentally retarded (EMR)— | refers to mildly impaired group, usually includes ~ 85% of all people with CI
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| Classification of Cognitive Impairments Trainable mentally retarded (TMR)— | refers to child with moderate levels of cognitive impairment, accounts for ~ 10% of intellectually disabled population
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| When a child with mental retardation is hospitalized, what can be done to help the child adjust? | Allow a parent to stay with the child; allow the child to be as independent as possible; focus on things the child can do.
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| Fragile X | Caused by abnormal gene on the lower end of the long arm of X chromosome
Fragile site noted on the DNA and is replicated in affected individuals
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| What is the most common chromosomal abnormality? | Down syndrome.
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| What role does the nurse play in assisting a child with a cognitive impairment? | : The major role is in supporting and educating the family.
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| Bacterial Meningitis | : an inflammation of the meninges, the covering of the brain and spinal cord
Incidence: most common for children under 2 months
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| Most Common Causative Agent for Bacterial Meningitis: | Group b streptococcus (GBS) (under 2 months)
Streptococcus pneumoniae
Neisseria meningitidis
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| definitive diagnostic for Bacterial Meningitis: | Lumbar puncture is the definitive diagnostic test
CSF
Culture
Gram stain
Blood cell count
Glucose and protein content
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| Bacterial Meningitis interventions | Isolation precautions
IV antibiotics
Restrict hydration
Maintenance of ventilation
Reduction of increased ICP
Management of shock
Control of seizures
IV infusion
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| What is Kernig sign? | A sign indicating the presence of meningitis.done by having the person lie flat on the back, flex the thigh so that it is at a right angle to the trunk,extend the leg at the knee joint. The leg cannot be completely extended due to pain.
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| What does a Brudzinski sign? | 1.
An indication of meningitis in which passive flexion of the leg on one side causes a similar movement in the opposite leg.
2.
Such an indication in which passive flexion of the neck causes flexion of the legs.
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| What initial medication management plays a role in ICP. | Dexamethasone
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| : What is the most common causative agent of bacterial meningitis in children? | Streptococcus pneumoniae and Neisseria meningitidis.
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| : What is the importance of clustering nursing care? | To allow maximum rest and keep stimulation to a minimum.
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| Encephalitis Pathophysiology | Inflammation of the brain parenchyma.
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| Causative agents include Encephalitis Pathophysiology: | Togaviruses and herpes virus type 1 and 2.
protozoa
Bacteria, spirochetes and fungi.
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| Encephalitis Manifestations | Headache, dizziness, coma.
Spasticity
Fever
Seizures
Lethargy
Vomiting
Stiff neck (nuchal rigidity)
Altered Mental Status
Tremors
Ocular Palsies
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| Which age group is most at risk for residual damage as a result of encephalitis? | Infants.
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| Reye’s Syndrome | an ACUTE NON-INFLAMMATORY encephalopathy and HEPATOpathy, with NO reasonable explanation for the cerebral and hepatic abnormalities.
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| Reye’s Syndrome Etiology | Etiology: actual cause unknown.
Most cases follow a common illness, typically influenza or varicella
Use of ASPIRINE to treat symptoms associated with onset of syndrome.
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| Reye’s Syndrome DiagnosTic evaluation | Lab results:
Elevated ammonia levels.
Cerebral edema with ICP.
Definitive diagnosis: Liver biopsy.
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| What drug should not be given to a child to treat symptoms associated with chickenpox? | Aspirin.
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| What should be monitored when caring for a child with Reye's syndrome? | Respirations, neuro status, vital signs and I & O.
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| Sepsis Pathophysiology | Sepsis or septicemia, refers to a generalized bacterial infection in the bloodstream that can progress to systemic inflammatory response syndrome (SIRS), shock, multiorgan system failure and death.
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| Sepsis can occur as a ______ or _____infection (following another infection). | primary OR secondary
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| Sepsis Pathophysiology: Neonates/Children at risk: | neutropenic, immunocompromised or in intensive care (due to invasive procedures
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| Sepsis Manifestations | Poor temperature control.
Tachypnea.
Tachycardia.
Hypotension.
Neurological signs such as lethargy.
Jaundice.
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| SEPsis Diagnostic tests | Positive blood culture.
Urine culture.
Cerebrospinal fluid culture.
Anemia.
Immature WBCs and neutropenia are ominous signs.
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| Sepsis Nursing care | Monitor neuro status and vital signs.
Observe for shock.
Administer IV antibiotics as ordered, 7-10 days if positive culture.
Verify vaccination against H. influenza type B (Hib) for all children between 2 months and 4 years.
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| What neonate/children are most at risk for developing sepsis? | : Neutropenic, immunocompromised or in intensive care unit.
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| Seizures* | are caused by excessive and disorderly neuronal discharges in the brain.
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| Seizure Manifestations depend on site of origin and may include: | Unconsciousness or altered consciousness.
Involuntary movements.
Changes in perception, behaviors, sensations and posture.
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| Epilepsy* | Is a condition characterized by two or more unprovoked seizures
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| Etiology of Epilepsy | Classified by type and etiology
Some are caused by:
Trauma.
Hypoxia.
Infections.
Biochemical events.
Fevers greater than 101.8 with rapid elevation.
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| Partial seizures: 3 types: | Simple partial seizures.
Complex partial seizures.
Simple or complex seizures/
secondarily generalized
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| Generalized seizures: | May occur at any time, includes both Hemi of the brain, they have no memory of the event.
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| Diagnostic Evaluation/Thorough history and physical. Diet review. Examining the seizure: | Onset.
Time of day.
Any precipitating factors.
Duration.
Progression.
Postictal feelings.
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| Antiepileptic drugs: Primary therapy is giving appropriate drugs or combination of drugs in the dosage that provides the desired effects without undesirable side effects. | Primary drugs for partial seizures and/or tonic clonic seizures:
Carbamazepine (Tegretol).
Phenytoin (Dilantin).*
Valproic Acid (Depakote).
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| Primary drugs for absence seizures: | Ethosuzimide (Zarontin).
Valproic Acid (Depakote).*- requires good oral care.
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| Continuous seizure that lasts more than_____ minutes. | 30 min
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| Status Epilepticus | A series of seizures where the child does not regain a premorbid level of consciousness.
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| What are some possible causes of seizures? | : What should you document if you observe a child having a seizure?
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| What should you document if you observe a child having a seizure? | Activity before seizure, body movements, change in color, respirations, muscle tone, incontinence, body parts involved, duration and appearance, behavior and LOC after the seizure.
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| Gross motor infant | Head control
Head lag
Rolling over
Sitting
Locomotion
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| Infant Fine motor | Prehension
Palmar grasp
Pincer grasp
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| Toddlers Gross motor | Locomotion
Walking
Running
Up and down stairs
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| Toddlers Fine Motor | Fine motor
Increasing manual dexterity
Pincer grasp to throwing ball
Building towers
Drawing
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| Preschoolers gross motor | Walking, running, climbing, jumping well
Refinement of eye-hand muscle coordination
Rides trike, skips, jumps rope
Refinement of eye-hand muscle coordination
Rides trike, skips, jumps rope
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| Preschool Fine motor |
Increasingly skillful manipulation
Drawing
Dressing self
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| School-age | More graceful
Posture improved
Double strength
Muscles immature
“age of loose tooth”
“ugly duckling stage”
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| Adolescents | Sexual maturation
Final 20-25% of height is achieved
Adolescent growth spurt
Characteristic sequence for growth
Extremities and neck
Hip and chest
Shoulder width
Trunk length
Depth of chest
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| Name one age-specific change for the infant, toddler, preschooler, school-age child, and adolescent. | Varies – any of above is correct
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| Immobilization | Congenital defects
Degenerative disorders
Infections or injuries
Musculoskeletal system problems
Neurologic system problems
Certain therapies
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| Name four of the most frequent reasons for immobility | Congenital defects, degenerative disorders, infections or injuries of skin, musculoskeletal system problems, neurologic system problems, therapies.
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| Soft tissue injury | Muscles
Ligaments
Tendons
Usually results from mishaps during play, common in children
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| Contusions | Bruise
Immediate treatment consists of cold application
Return to participation
Strength
Range of motion
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| Crush injury | A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy objects.
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| Crush injury treatment | Seek medical treatment
Release any subungual hematoma
Cold application
Treat any lacerations
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| Dislocations | Ligament involvement
Pain
Inability to move joint
Phalanges, elbow
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| Dislocation treatment | Simple dislocations should be reduced as soon as possible
Treatment depends on severity of injury
Restrict joint, cold application
Seek medical attention from ER or provider
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| Sprains | A sprain is an injury to the ligaments around a joint. Ligaments are strong, flexible fibers that hold bones together. When a ligament is stretched too far or tears, the joint will become painful and swell
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| related to sprain pain S/S | Severe
Joint laxity
Pain
“feeling loose” or “snap, pop, tearing”
Rapid onset of swelling, immediate disability
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| Explain the acronym RICE | Rest, ice, compression and elevation to reduce edema, bleeding and pain.
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| The 5 P’s: pain, pallor, pulselessness, paresthesia, paralysis | What things need to be included in the assessment of a child with a suspected fracture?
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