Patient care

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Chapter 4 Patient care

Sarah Fearn

CHAPTER CONTENTS

Introduction 41
Assessing the patient 42
Paediatrics 42
The elderly patient 46
Mental health problems 49
The trauma or emergency patient 50

KEY POINTS

image Every patient is individual; no two persons react in the same way to a given situation.
image Prescriptive guidance with regards to patient care is not appropriate. There is no magic formula when caring for patients and skill must be developed in assessing and adapting to the needs of patients on an individual basis.
image In addition to caring for the patient, it is important to consider the needs of those accompanying the patient, such as friends, relatives or carers.

INTRODUCTION

Patients, no matter who they are or why they are attending hospital, are affected emotionally and physically by illness and pain. Whilst every patient is unique and will cope in their own way, this chapter examines aspects of patient care for a variety of patient groups from paediatrics and the elderly to those involved with trauma or with mental health problems.

When reading the chapter consider that issues discussed in the context of a specific patient group may also be relevant to other patients. For example, visual impairment is most common amongst the elderly population; however, the guidance given regarding this can equally be applied to all visually impaired patients, regardless of age.

ASSESSING THE PATIENT

It is difficult to care for a patient appropriately without first assessing their needs, and anticipating these as early as possible ensures a more pleasant patient experience. When assessing a patient’s needs, the following questions may be helpful:

Who is the patient?

• What is his age? (This will often affect the approach taken to his care.)
• Does he have special needs, such as a hearing impairment or a learning disability?
• What is his level of understanding?
• What is his level of mobility?
• Are there any cultural or religious issues to consider?

Why is he here?

• Is the examination routine or is the patient symptomatic? (This may influence the patient’s feelings and anxiety levels and also his behaviour.)

What examination is being undertaken?

• How long is the patient likely to be in the department?
• How invasive is the procedure?
• Are detailed explanations required?
• What aftercare will be needed?

PAEDIATRICS

Paediatrics range from the neonate to the young adult and each age presents a different challenge. A child in the hospital environment is faced with strange sights, smells and sounds which can be very frightening. The experience of visiting or staying in hospital may affect subsequent visits, and fears may be carried into adult life. Ensuring a child is as comfortable as possible is therefore essential. Before examining each age group, there are several general points to consider.

GENERAL ISSUES

Preparation

Prior to the child attending for examination:

• Preparation of the child and parent or guardian is extremely important.
• Play has an important role in helping a child relax and, although not always available, the use of a play specialist can help in preparing a child for a potentially distressing situation.1
• Child friendly leaflets (Fig. 4.1) can help explain information to a child using simple language and pictures.
• Remember that in order for the parents to prepare a child for an examination, they also need to understand clearly what is involved.
image

Figure 4.1 Child friendly leaflets.

Once the child has arrived in the department:

• Ensure the waiting area and examination room are a pleasant temperature.
• Ensure all equipment is ready and a preliminary exposure is set to minimise the time the child spends in the room.
• Ensure help is readily available before bringing the child into the room.
• Think carefully how the examination will be carried out, having age-appropriate toys and distractions ready.

Is it our turn next Mummy?

It is inevitable that children will sometimes have to wait before an examination; however a child- friendly environment is likely to encourage a child to feel at ease.2

• Where possible a separate waiting area for paediatrics can have several benefits:

– It is less stressful for parents who do not have to worry about other patients.
– The child can be more easily distracted with toys and books whilst waiting.
– A quieter area, avoiding the hustle and bustle of a busy waiting area, can help calm the child prior to his examination.

• Keep waiting times to a minimum to avoid children becoming restless.
• Keep time spent in the examination room to a minimum.

Dealing with parents and guardians

Parents are often extremely anxious and it can be as much of a challenge caring for them as for the child. Remember that anxiety can result in an overprotective parent who may be more irritable and less patient than usual. When dealing with the parent:

• Plenty of reassurance is often needed, although be careful not to falsely reassure.
• Remain patient and calm at all times and ensure you are firm yet polite.
• Do not separate the parent and child unless absolutely necessary; use discretion with the older child.
• Involve parents in the care of the child, informing them what you are doing and why. This helps to make them feel more in control.
• Remember that parents know their children extremely well and will often be able to communicate with them more effectively than a stranger. Utilise this when providing explanations or instructions or if a child needs distraction.

In the past there have been many approaches to keeping children still for radiographic examinations, some of which today are considered inappropriate. Restraining a child should be the last resort. It is preferable to take time to build a rapport with the child in order to gain his trust. If the child is unable to keep still on his own, consider that the presence of a familiar face may be comforting enough to achieve this; for example sitting the child on a parent’s lap.

Lastly, it may seem obvious but never leave a baby or toddler unattended, not even for a second. Even if a baby does not appear to be on the move, it only takes a moment for a him to roll over when your back is turned and this could result in serious injury, especially if he falls from a height.

AGE-SPECIFIC ISSUES

Having considered the general issues, paediatrics have been grouped into the following five age ranges:

• Neonate
• Older baby or toddler
• Pre-school child
• Primary school child
• Older child and young adult

Guidance is provided on how to deal with the issues and challenges associated with each age group, although it must be remembered that each child is unique and will develop at his own pace.

The neonate

Babies up to the age of one month are termed neonates (Fig. 4.2). These babies are most commonly encountered on the Special Care Baby Unit (SCBU), although remember that not all neonates requiring imaging are admitted to hospital.

• The neonate will be more likely to remain settled if they are warm and comfortable. Maintaining warmth is important as the neonate loses heat very quickly; therefore, if he must be undressed, ensure that this is for as short a time as possible
• Always minimise movement of the baby, as this is unsettling
• Ensure all examinations are performed quickly and efficiently
image

Figure 4.2 The neonate.

Consider that parents of the neonate:

• may be shocked at the early arrival or the poor health of their baby and may need time to adjust
• are likely to be extremely anxious and this may cause changes in behaviour
• are likely to be protective of their child.

With regards to the mother, she may have had a traumatic birth and hormone levels are likely to affect her behaviour.

When dealing with the neonate on SCBU:

• Always seek permission from SCBU staff and wait for their assistance before beginning any examination.
• The neonate will often have numerous lines and tubes connected to him and care should be taken not to dislodge these.
• Minimise handling of the neonate as this can affect oxygen saturation levels.
• Avoid leaving the incubator open for any length of time so as to maintain warmth, and use hand holes where possible.
• Infection control is important:

– Disposable gloves and apron should be worn and changed between patients.
– X-ray equipment such as cassettes should be covered and cleaned.
– Hands should be washed before and after contact with each baby.

The older baby or toddler

Although young babies tend not to mind who picks them up, as they become more aware of the world around them they begin to become upset if separated from their parent (Fig. 4.3). It is important, therefore, to ensure a familiar person remains with them throughout their examination.

image

Figure 4.3 The older baby.

Although restraint should be considered a last resort, it is vital to remember that babies are unlikely to keep still unless they are sleeping. Holding of the baby by the parent or guardian is preferable to the use of restraining devices such as Bucky bands. In such a scenario, radiation safety is essential and the appropriate guidelines for holding patients should be followed. Older toddlers understand a significant amount and so techniques other than physical restraint may prove effective.

• If the child is old enough to understand then take time to build a rapport with the child in order to gain his trust.
• The presence of a familiar face may be comforting enough to achieve cooperation; for example sitting the child on a parent’s lap.3
• Distracting a child with a toy, or playing a game may be all that is needed to keep a child still.4

Keeping a baby or toddler as comfortable as possible prior to and during the examination is essential.

• A dummy or favourite toy may comfort the child and provide familiarity.
• Do not place baby on a cold surface; instead cover with a sheet.
• Do not undress a child unnecessarily as he can feel vulnerable when undressed and may also become cold.
• Where possible, ensure the baby is not hungry, as a hungry baby is likely to be unsettled.

The preschool child

Once a child has reached preschool age (3 years and above; Fig. 4.4), his ability to communicate and understand has developed sufficiently to now be aware of his surroundings. Often at this age the hospital environment can seem very frightening and the child is still likely to need his parent present. The need for restraining a child becomes less necessary and time should be spent adequately preparing the child and gaining his trust and cooperation.

• When speaking to young children, use simple language. You may wish to elaborate when speaking to the parent but be careful not to exclude the child in conversation.
• To increase cooperation, always explain why you or the parent or child has to do something.
• Repeat instructions or explanations where necessary, always checking that you have been understood. This may be achieved by demonstrating what is required. Using a teddy or doll or even the parent (without exposing) can also help allay fears.
• Always be honest with a child. If something is likely to hurt then do not tell the child that it will not. This may result in broken trust which is difficult to restore.
• Remember that a child who is anxious may regress in age and explanations should be tailored to this.
• Even a young child can get embarrassed when undressed; therefore always consider the child’s privacy, whatever his age.
• Consider using rewards such as stickers and certificates to motivate the child into cooperating.
image

Figure 4.4 The pre-school child.

The primary school child

Whilst it should become easier to gain cooperation, a child at this age will also be more aware of what is happening to him and distraction may not be as easy (Fig. 4.5). It is important not to treat the child like a baby, as if he is incapable of understanding, but neither is it acceptable to treat him as a little adult. Finding this balance can often be challenging, especially as different children develop at a different pace. Older children often like to feel independent and offering choices can help them to feel less vulnerable. Do bear in mind, however, that offering too many choices can also be overwhelming.

image

Figure 4.5 The primary school child.

The older child and young adult

As children get older and head towards adulthood they naturally become more independent and may wish to make their own choices with regards to their care. There is no set age at which a patient can take responsibility for their own treatment or care and if a child below the age of 16 is deemed as having sufficient understanding and intelligence, then they may be allowed to determine themselves whether or not they undergo hospital procedures. This is termed ‘Gillick competence’.5 Whilst parents of older children may still wish to accompany their child for an examination, discretion may be needed at times. For example, asking a teenage girl about pregnancy.

NON-ACCIDENTAL INJURY

Non-accidental injury (NAI) can be ‘physical or mental injury, sexual abuse, negligence or maltreatment of a child’.1 Where this is suspected, the child is likely to undergo a skeletal survey. Whilst skeletal surveys for NAI should be performed by two experienced radiographers, if asked to assist or care for the patient it is important to consider the following:

• Parents may be allowed to accompany the child; however, the need for the examination should have been explained to the parents by the paediatrician prior to any interactions with the imaging department.
• If a parent accompanies the child, staff should remain polite and non-judgemental. Remember that NAI has not been confirmed and is only suspected at this stage.
• Never leave the child unattended. Two members of staff should remain with the child at all times, to act as each other’s witnesses.

THE ELDERLY PATIENT

With a continuing rise in the elderly population6 it is inevitable that the number of elderly patients you will encounter is also on the increase. Just because a patient is elderly does not mean that they should be treated any differently. Older patients may feel vulnerable and worry about illness not just because of how it affects them personally but also how it may affect those that they care for, such as partners or pets. Many elderly patients have few visitors and may wish to talkat length to relieve their loneliness. In a busy department it can be difficult to devote this extra time; however, these patients may benefit significantly if they feel you have the time to listen.

Problems with mobility, sensory loss and dementia are perhaps the most common problems encountered with the older patient.

MOBILITY

Reduced mobility can mean anything from the patient confined to bed to the patient who is able to mobilise with a little help. The numerous causes range from loss of confidence following a fall to recovering from surgery.

Prior to the examination the following should be considered:

• Is the patient steady on his feet or able to stand still? Just because a patient has no obvious mobility problem does not mean that he will not require assistance.
• Patients with reduced mobility may need help changing, and therefore help should be offered.
• Choose the most appropriate examination room for the patient. For example, a larger room would be more suitable if it allows a bed to be more easily manoeuvred.
• If you foresee difficulties, ensure extra help is readily available.

Where the patient has a walking aid such as a frame or stick:

• Will the patient be able to let go of his walking aid if required? If this is necessary, ask the patient’s permission before taking it away, returning the walking aid to the patient as soon as possible.

Where the patient is a wheelchair user:

• Consider why the patient is in a wheelchair and whether the wheelchair use is permanent or temporary (e.g. whilst they recover from surgery).
• Consider access to changing and toilet facilities. Always offer help and allow adequate time.
• Check with the user of a self-propelled wheelchair before pushing the chair. Some users may be offended if you push them when they can propel themselves.
• Do not presume that a wheelchair user cannot mobilise. It may be useful to ask the patient questions about his daily routine at home or on the ward to assess whether it is safe to get him out of the chair.
• If the patient is unable to mobilise and you must transfer the patient, ensure that moving and handling guidelines are followed and that equipment is used effectively and with training.

Where the patient is in bed:

• Consider why he is in bed and whether he can mobilise.
• Allow extra time with the patient and prepare the examination room in advance.
• Ensure you do not attempt to move a patient who is not allowed to mobilise; e.g. a patient who is postoperative.
• If the patient is unable to move himself then consider whether the patient can remain in the bed. If the patient cannot mobilise but must be transferred from the bed, always seek help, utilising moving and handling aids.

VISUAL IMPAIRMENT

Many patients suffer visual impairment, which may or may not be age related. The amount of help required will differ for each patient and may depend on the degree of visual impairment.

• Remember that many visually impaired patients remain independent and cope well with everyday life.
• Ensuring adequate lighting can often help a person to see more clearly.
• Do not remove a person’s glasses unless absolutely necessary, and always return them to the patient promptly.
• If the patient requires guiding, do so slowly and carefully, avoiding obstacles and telling the patient where he is going.
• Always explain what you are doing or about to do: a person with poor sight will rely on your explanation.
• Always tell the patient if you leave the room, so that they do not feel isolated.

HEARING IMPAIRMENT

It can prove embarrassing for a patient to misunderstand due to poor hearing and patients will often not want to admit that they have not heard or understood. The following points should therefore be considered:

• Do not rely on simply calling the patient’s name. It should not be assumed that no response means that the patient is not present. Look around the waiting room and collect the patient if necessary.
• Be extra careful when checking the identification of the patient. They may have mistaken another patient’s name for their own, which could lead to an incorrect examination being performed.
• Reduce the level of background noise wherever possible. A patient with a hearing impairment may struggle when surrounded by high levels of background noise. A quieter environment may help.
• Do not remove hearing aids unless absolutely necessary and always return them to the patient as soon as possible.
• Use facial expressions and gestures to give visual clues as to what you are trying to communicate.
• Speak in close proximity to the patient, being careful not to invade his personal space.
• Raising your voice may help, but be careful never to shout. It will be obvious to the patient that you are doing so and this may be offensive.
• Speak clearly and slowly, allowing enough light for the patient to see you.
• Always face the patient when speaking, to allow them to lip read if they are able to do so.
• Consider using written instructions.

DEMENTIA AND ALZHEIMER’S DISEASE

It must be remembered that not all older people have memory problems or are senile, and we should not treat elderly patients as such; however, as people age, many undergo mental changes. Knowing how to deal with these patients effectively is essential. Dementia is a ‘progressive deterioration in intellectual functioning’,7 affecting thinking, remembering and reasoning. Alzheimer’s disease is the most common form of dementia and, in its early stages, forgetfulness and personality change are common features. As the disease progresses, it affects daily life more and more, reaching the stage where verbal communication is limited and the patient fails to recognise family members. It can be very distressing for friends and relatives to see someone they care about change in this way and they often need as much consideration and reassurance as the patient himself. When dealing with the patient with dementia:

• Treat the patient with respect, protecting his dignity and upholding his privacy.
• Comfort the patient, making him feel secure with plenty of reassurance.
• Consider the patient’s friends and relatives, be approachable and show interest in their needs.
• Be patient. Confusion often requires instructions or explanations to be repeated several times before they are understood.
• Speak directly to the patient and do not be dismissive.
• Avoid changes of staff where possible to ensure consistency and to enable the building of trust.

OTHER ISSUES RELATING TO THE ELDERLY

Fragile skin

With age, skin becomes more fragile and susceptible to injury. This should be considered when assisting patients and extra care should be taken. Sharp edges, for example, can easily cause damage.

Falls

Falls are a major cause of disability and can lead to mortality in the elderly population.8

• Always consider that patients who are seemingly quite stable on their feet can suddenly lose balance and fall.
• If patients have previously fallen, they may also have a fear of falling, affecting their confidence in mobilising.
• Seek to prevent the risk of a patient falling by ensuring there are no potential hazards in the department, such as slippery floors or poor lighting.

Continence

Many elderly patients experience problems with control of bladder and/or bowel movements. This can lead to problems with hygiene and cross-infection. Patients suffering from incontinence of urine may have a urinary catheter and this should be considered. Where the patient has a urinary catheter:

• Be careful not to pull or catch the urinary catheter. Catheters are easily forgotten if attached to the patient’s bed and may be tugged or pulled when transferring a patient.
• If a patient is in a wheelchair, ensure his catheter comes with him if he mobilises, and that it is positioned so that it does not pull.
• Patients with long-term urinary catheters often have a leg bag attached to their leg, which is then hidden under clothing. Consider this when asking a patient to undress for an examination as it may cause embarrassment if he has to wait with other patients.

MENTAL HEALTH PROBLEMS

At any one time, one in six adults suffers from a form of mental illness ranging from depression to schizophrenia.9 Many patients will not require any special care, whilst others may prove challenging. Although the range of mental health problems is vast, here we consider three commonly encountered disorders. Note that dementia is discussed earlier in the chapter.

DELIRIUM/CONFUSION

This has many causes including medication, infection and head injury. Delirium has a sudden onset and is usually short lived, causing confusion, fluctuating awareness, short-term memory loss and disorientation.7 When caring for these patients:

• Protect them from harm; never leave them unsupervised.
• Ensure quiet surroundings where possible, as noise can cause agitation.
• Speak in a calm voice, using simple language and be prepared to repeat instructions and explanations.
• Give plenty of reassurance, especially if they become embarrassed or ashamed of their behaviour.

SCHIZOPHRENIA

Patients with schizophrenia can have many symptoms, ranging from delusions and hallucinations to social withdrawal. Patients may be aggressive, struggle to make decisions and may exhibit strange behaviour and speech. When dealing with these patients:

• Avoid retaliating to the patients’ behaviour, even if this appears socially unacceptable.
• Speak calmly and avoid being sharp or critical.
• Do not offer such patients too many choices or force them to make decisions by themselves.
• Neither agree or disagree with the patient’s ideas.
• Consider the need to calm a potentially aggressive patient and bring a situation under control.
• Remember that friends or relatives may be distressed and may appear irritable or intolerant.

LEARNING DISABILITIES

A person with a learning disability has impaired intellectual and social functioning, and often has difficulty understanding, communicating andremembering new things.8 These difficulties are present at birth or in early childhood but often continue into adult life. Patients with learning disabilities are not all the same and each patient will have different needs. Despite this, there are several general considerations when caring for these patients:

• Consider that it may be useful to involve a friend, carer or relative in the examination as she may know how best to gain cooperation from the patient.
• If the patient is accompanied by a friend, relative or carer, ensure you talk directly to the patient so he feels included.
• Talk to the patient using language appropriate for his level of understanding.
• Avoid asking the patient too many questions or providing too many choices.
• Be patient and be prepared to repeat instructions several times.
• A patient may respond to a demonstration of what is required rather than a verbal explanation.

THE TRAUMA OR EMERGENCY PATIENT

EMOTIONAL ISSUES

Emergency situations undoubtedly arouse emotions in both patients and relatives, often due to the suddenness with which events have taken place. You will encounter many patients and relatives who, due to a sudden illness or traumatic event, will exhibit high levels of anxiety and emotional stress, often causing them to behave in an uncharacteristic and apparently unreasonable manner. It is therefore important to consider how to deal effectively with them:

• Highly emotional patients may not be able to absorb information or follow instructions and so patience is required to ensure that they fully understand, even if this means repeating it several times.
• Patients and relatives often take their cues from the staff who care for them and therefore remaining calm and confident can help to reduce anxiety.

DEALING WITH AGGRESSION

Anger and aggression are common reactions following a traumatic event and can also be linked to alcohol or drug use. Knowing how to defuse a potentially violent or threatening situation is important in protecting yourself and others.

• Unrealistic expectations are often linked to aggressive behaviour and therefore good communication, especially with regards to waiting times, can help to remove the frustration which can lead to aggression. Minimising waiting times and providing a pleasant waiting area may also help.
• Consider that your body language and facial expressions, as well as the language you use, can affect a patient’s behaviour. Speaking in a calm, non-confrontational voice with normal pitch and volume can help to keep the situation under control.10 Do not be tempted to shout back at a patient as this will only provoke aggression.
• Do not leave yourself alone with a patient if you feel that your personal safety may be at risk. Always request the presence of another member of staff.
• Ensure that a patient does not come between you and your exit from a room. This allows for rapid escape should a patient become violent.

PATIENTS ON A TRAUMA TROLLEY

Patients will be encountered who are immobilised on a trolley (Fig. 4.6), often due to suspected spinal injury. When dealing with these patients:

• Never move the patient, unless given permission by medical staff.
• Ensure patients are aware of the importance of keeping still. Re-iterate this several times if necessary. Remember that it may be very frustrating for patients if they are either unable or not allowed to move.
• If a patient must be moved, then this must only be carried out with the assistance of the trauma team in a controlled manner; i.e. log rolling.
• Always follow moving and handling guidelines.
• When talking to the patients, ensure that they can see you clearly and always explain carefully what you are doing.
• Avoid leaving the patient unattended where possible. Uncooperative patients may attempt to move or even remove themselves from the trolley and this could result in further injury.
image

Figure 4.6 The immobilised patient.

PAIN

Trauma patients are often in a significant amount of pain and this can influence cooperation. Pain is an individual experience and, as such, the same injury can cause differing levels of pain. It is not therefore appropriate to judge pain level by the severity of an injury alone.

• Ensure that if necessary, and where possible, pain relief has been administered prior to the examination.
• Whilst movement should be minimised, there will be occasions when causing pain is unavoidable and this should be explained to the patient.
• Reassure the patient and explain what you are doing and why.
• Be honest. If you are likely to cause pain, then tell the patient, explaining why it is necessary.

FRIENDS AND RELATIVES

When dealing with friends and relatives of the trauma or emergency patient:

• Reassure and care for them as well as the patient.
• Explain carefully to them what is happening and make them feel involved, being careful not to breach confidentiality.
• Use discretion as to whether they should accompany the patient for the examination. They may find the examination distressing, especially if they see the patient uncomfortable or in pain. Some patients, however, may be more cooperative if they can see a familiar face during an examination.

THE UNCONSCIOUS PATIENT

There are several considerations when caring for the unconscious patient:

• Ensure protocol is followed carefully when identifying the patient. Do not assume other staff have identified the patient.
• The patient is likely to have several lines, tubes and/or drains in situ:

– Be very careful not to catch or pull these.
– If moving the patient, be careful of tubes and drains attached to the bed or trolley.
– Do not empty containers such as catheter bags without first seeking permission, as the contents may need measuring.
– If the patient is being artificially ventilated, ensure that this is not accidentally disconnected. Ventilated patients should always be accompanied by the appropriate medical team and should never be left unattended.

• Whilst unconscious patients may not be able to communicate with you, they are often still aware of their surroundings11 and therefore will benefit from physical contact and reassurance.
• Effective teamwork and communication are essential when caring for any patient, but never more so than where the patient is unconscious. Speed and efficiency are required to ensure risks to the patient are minimised.

References

1 Hardwick J, Gill C. Radiography of children: a guide to good practice. Edinburgh: Elsevier, 2004.

2 Drummond M, York C. Evaluating paediatric practice and care. Synergy. 2001;Feb:20-21.

3 Kurfis Stephens B, Barkey M, Hall H. Techniques to comfort children during stressful procedures. Accid Emerg Nurs. 1999;7:226-236.

4 Martin A. Salthouse. Imaging children: do’s and don’ts. Synergy. 1999;Aug:11-13.

5 Dimond B. Legal aspects of radiography and radiology. Oxford: Blackwell, 2002.

6 Coni N, Nicholl C, Webster S, Wilson K. Lecture notes on geriatric medicine. Oxford: Blackwell, 2003.

7 Bauer B, Hill S. Mental health nursing: an introductory text. Philadelphia: WB Saunders, 2000;101.

8 Department of Health. Valuing people: a new strategy for learning disability for the 21st century. London: HMSO, 2001.

9 Department of Health. National service framework for mental health. London: HMSO, 1999.

10 Walsh M, Kent A. Accident and emergency nursing, 4th edn. Oxford: Butterworth Heinemann, 2001.

11 Rideout A. The unconscious patient. Toulson S, editor. Accid Emerg Nurs. 2001:142-171.

Recommended reading

Culmer P. Chesneys’ care of the patient in diagnostic radiography. Oxford: Blackwell, 1995.

The early chapters of this text provide guidance on general aspects of patient care; such as dealing with aggression and preparation of the patient. There is also a helpful chapter on working with trauma and acutely ill patients..

Gunn C, Jackson C. Guidelines on patient care in radiography, 2nd edn. Edinburgh: Churchill Livingstone, 1991.

Although now dated, this clearly written text covers all aspects of patient care. Focus is given to a variety of patient groups and guidance provided on patient psychology..

Hardwick J, Gill C. Radiography of children: a guide to good practice. Edinburgh: Elsevier, 2004.

Easy to read guidance on all aspects of paediatric radiography. Whilst focussing on radiographic technique, the more general aspects of paediatric patient care are comprehensive..

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