3. Settings for Care
Hospital
24-hour observation
Emergency hospitalization
Outpatient and day facilities
Rehabilitative care
Medical-surgical unit
Intensive care unit
School-based clinics
Community clinics
Home
4. Common Stressors and Children’s
Response to Hospitalization/Illness
Fear of the unknown
Separation anxiety
Fear of pain or mutilation
Loss of control
Anger
Guilt
Regression
5. Infant
Experiences some
separation anxiety at
about 6 months of
age
They can sense the
anxiety their parents
are experiencing
6. Stages of Separation
Protest Despair Detachment
Screaming, crying, Child becomes Lack of protest when
inconsolable hopeless and becomes parents leave
quiet, withdrawn,
Clinging to parents apathetic Appearance of being
happy and content
Agitated Sadness, depression with caregivers and
other children.
Resists caregivers Withdrawal or
complaint behavior Close relationships
not established
Crying when parents
appear If parents reappear,
child may ignore.
7. Toddlers
**Separation anxiety
Nurses experience
protest and despair in
this group
Fear of injury and
pain
Regressive behavior
8. Preschooler
Separation anxiety
generally less than the
toddler
Less direct with protests;
cries quietly
May be uncooperative
Fear of injury
Loss of control
Guilt and shame
9. School Age Child
Separation: may have
already experienced
when starting to school
Fear of injury and pain
Want to know reason
for procedures and
Like being involved and
wants to make choices
10. Adolescence
Separation from friends rather
than family more important
Fear of altered appearance
Will act as though not afraid
when they really are.
Give them some control to
avoid a power struggle
12. Children’s Understanding of
Hospitalization
A child or adolescent bases
their understanding of
hospitalization on:
Cognitive ability at various
developmental stages
Previous experiences with health
care professionals
13. Families Response to
Hospitalization
Hospitalization is disruptive to the family’s
usual routines
May lead to change in roles
Family members are anxious and fearful
14. Nursing Care to Assist the
Child with Hospitalization
Related to Age
15. Infant – Trust vs. Mistrust
Encourage parent to visit / rooming in
Encourage parents to participate in care, Teach parents
procedures they are capable of doing
Discuss arrangements for care of other family at home
Try to simulate home routine
Try to assign same nurse
Allow parents to be present during procedures and
comfort afterwards
Keep frightening objects from view
Provide swaddling, soft talking to soothe
Play close attention to light and sound stimulation
Allow non-nutritive sucking for comfort
16. Older Infant / Toddler
Autonomy vs. Shame and Doubt
Encourage parent to room in and if have to leave, leave
when awake and leave something of meaning with child
for support.
Provide warmth and support
Explain to parent stage child is in
Bring infants security object -- favorite toy, blanket
Set limits, give choices on simple decisions
Teach parents child may regress, may promote potty
chair if child is trained. Offer frequently (4x per shift)
Promote ritualistic behavior for bedtime
Teach parents about hazards (crib, chair, toys,
equipment) be sure to supervise when out of crib.
17. Preschooler – Initiative vs. Guilt
Acknowledge child’s fears regarding hospitalization
Orient to the hospital, spend time with child to build trust
Encourage presence of parent if possible and encourage to
participate in care. Provide comfort and support .
Nutrition – assess food likes (hamburger, PBJ sandwich, etc)
Give small portions. Make environment comfortable and
accept messes. Encourage intake of fluids with games.
Provide consistent environment ; Reinforce coping behavior
Provide with as much mobility as possible
Provide play and divisional activities
Avoid intrusive procedures as much as possible
Assess child’s perception by asking to draw a picture and tell
about it
18. Pre Schooler
This pre-schoolers parents are taking the time to
prepare her for hospitalization by reading a book
recommended by the nurse. Such material should be
appropriate to the child’s age and culture. Why do
you think that having the parents read this material is
valuable?
See Box 35-2
p. 891
19. School Age – Industry vs.
Ascertain what child knows. Clarify using scientific
terminology and how body functions
Direct questions more to the child when teaching them
(help master over feelings of inferiority)
Use audiovisuals, pictures, body outlines.
Suggest ways of maintaining control (i.e.: deep
breathing relaxation).
Gain cooperation. Give positive feedback
Include in decision-making (time to do it, preferred site).
Encourage active participation (removing dressings,
doing PIN care). Plan child’s day if possible with child’s
input
Maintain clear and consistent limits
Allow for privacy
20. School Age Child
Allowing the child to dress up as a doctor or a nurse helps
prepare the child for the hospitalization experience.
This helps the child adjust to treatment, care, and the
recovery process.
21. School Age Child
The child’s anxiety and fear often will be reduced if the nurse
explains what is going to happen and demonstrates how the
procedure will be done by using a doll. Based on your experience,
can you list five actions you can take to prepare a school-age
child for hospitalization?
22. School Age Child
Some hospitals offer a special classroom and teacher for children
undergoing a lengthy hospital stay, enabling them to remain current
with their school work. The child who falls behind other students
might not fit in when he or she returns to school or might be required
to repeat a grade.
23. Adolescent – Identity vs Identity Diffusion
Assess knowledge.
Encourage questioning regarding fears, or risks.
Involve in decision-making.
Ask if patient wants parent there.
Make as few of restrictions as possible.
Suggest ways of maintaining control.
Accept regression to more childish ways of coping.
Give positive reinforcement.
Provide privacy for care
Encourage to wear street clothes and perform normal
grooming
Allow favorite food to be brought in if not on a special
diet
24.
25. Advantages of play to the
hospitalized child
Therapeutic – activities are guided
Emotional outlet – acts out real stressors
Used to teach child prior to situation
Enhances cooperation – used during an
unpleasant procedure.
26. Therapeutic Play Techniques
Infant
Crib Mobiles
Soft toys
Music
Toddler
Play peek-a-boo or Hide-and-Seek
Read familiar stories
Play with dolls that have similar “illness” as them
Puzzles, building blocks, push-and-pull toys
Play with safe hospital equipment – bandaids,
stethoscopes, syringes without needles. – remove
when finished playing
27. Therapeutic Play Techniques
Pre-schooler
Play with safe hospital equipment
Crayons and coloring books,
Puppets, Felt and magnetic boards
Books and recorded stories
Videos
School-age
Dolls
Hospital equipment
Board games, crafts
Books, computers
28. Pet Therapy
Hospitals may have pet therapy from specially
trained animals to provide comfort and distraction
during healthcare.
29. Children with Special Needs
For those with visual or hearing impairment –
provide material in auditory, tactile, or visual
means to assist child
Provide special equipment for those with
psychomotor difficulties
During patient teaching - provide more
reinforcement and shorter teaching sessions
30.
31. Nursing Measures to Tailoring
Care
Encourage positive communication with health
care team
View care as a partnership
Be aware that the parents are the
ones who knows the child best
Provide support to the parents,
allow them to assist with the care
Recognize influences of cultural background
32. Preparation
Tour of the Hospital or surgical area
Photographs or a videotape of medical
setting and procedures
Health Fairs
Contact with peers who had similar
experience
33. Preparation Strategies
Allowing the child to
dress up as a doctor
or a nurse helps
prepare the child for
hospitalization.
This helps the child
adjust to treatment
care and the recovery
process.
34. Things Parents can do to
Prepare Child
Read stories
Talk about hospital and coming home
Encourage child to ask questions
Visit a hospital or surgical area and allow
to touch equipment
Encourage child to draw pictures of what
they think it will be like
Be honest and tell about pain, etc.
35. Nursing Care to Assist Families to Cope
Orient to hospital
Assess what parent/child know of illness and treatment
Assess teaching needs - keep updated on condition of
child
Reinforce and encourage questions
Discuss ways the parents can participate in the care
Assess & discuss family support, make referrals
36. Nursing Care to Assist Families to Cope
It is important to allow the parents to be a part of the
child’s care.
Reunite the family as soon as possible after surgery. This
child has just undergone surgery and is in the post
anesthesia care unit (PACU). Although the child’s
physical care is immediate and important, remember that
both the child and the family have strong psychosocial
needs that must be addressed concurrently. It is
important to reunite the family as soon as possible after
surgery.
37. Preparation for Procedures
Take the child to a treatment room
Encourage a parent or loved one to provide
comfort and support
Use developmentally appropriate terminology
Offer the child choices
Tell the child and family how they can help with
the procedure
Do not threaten punishment for lack of
cooperation
Do not force an unwilling parent to stay;
encourage participation
38. Using Restraints
Use the least restrictive restraint
Choose proper device for condition
Ensure proper fit
Tie knots that can be untied easily for quick access
Secure ties to bed frames or another stable device
Frequently check the extremity distal to the restraint for
circulation, sensation, and motion
Remove restraints every 2 hours for range-of-motion
movement, repositioning and to offer child food or
opportunity to use the bathroom
Document findings from neurovascular checks
39. Child Life Specialist
A person who plans activities to provide age-
appropriate playtime for children either in the child’s
room or in a playroom.
Goal: Assist children to work through feelings about
their illness
40.
41. Myths About Pain
Neonates do not experience pain
Children have no memory of pain
There is a correct amount of pain for
a given injury
Children can easily become addicted
to narcotics
Narcotics can easily cause respiratory
depression
42. Pain Assessment
Neonatal characteristic facial responses to pain include: bulged brow, eyes
squeezed shut, furrowed nasolabial creases, open lips, pursed lips, stretched mouth,
taut tongue, and a quivering chin.
Physiological Response = increased B/P and decreased arterial saturation
43. Oucher Scale
After determining that the child has an
understanding of number concepts, teach
the child to use the scale. Pre-schooler
age is first to do this.
Point to each photo, explain that the
bottom picture is a “no hurt,” the second
picture is a “little hurt,” the third picture is
“a little more hurt,” the fourth picture is
“even more hurt” the fifth picture is “a lot
of hurt” and the sixth picture is the
“biggest or most hurt you could ever
have.”
The numbers beside the photos can be
used to score the amount of pain the
child reports.
44. Faces Pain Scale
Make sure the child has an understanding of number concepts
and then teach the child to use the scale.
Point to each face and use the words under the picture to
describe the amount of pain the child feels.
Then ask the child to select the face that comes closest to the
amount of pain felt.
45. Consequences of Pain
Cardiovascular and respiratory changes
Tachypnea, increased B/P and heart rate
Inadequate lung expansion, decreased arterial
saturation
Inadequate cough
Neurologic changes
Fight /flight response- Tachycardia, insomnia, glucose
Metabolic changes
Increased fluid and electrolyte losses
Immune system changes
Depression of immune system with increase in risk for
infection
Gastrointestinal changes
46. Pain Management
The presence of the
parent is an important
part of pain
management.
Children often feel
more secure telling
their parents about
their pain and anxiety
49. Administering Analgesics to
Children
The preferred routes are intravenous or
oral.
Infants and children receiving IV and
epidural opioids should be monitored by
pulse oximetry.
If respiratory depression occurs with
opioid use, naloxone hydrochloride should
be used for reversal when oxygen and
stimulation of the child are ineffective.
50. Nursing Interventions
When painful procedures are
planned, use EMLA cream to
anesthetize the skin where the
painful stick will be made.
Procedure :
Apply a thick layer of cream over
intact skin.
Cover the cream with a
transparent adhesive dressing,
sealing all the sides.
The cream anesthetizes the
dermal surface in 45 to 60 min.
Editor's Notes
1. What are the various types of settings where care is provided for the ill child?
2. What are some common children’s responses to illness and hospitalization and related nursing care.
2. What are some common children’s responses to illness and hospitalization and related nursing care.
3. Describe the stages of separation: Protest: child is agitated, resists caregivers, cries, and is inconsolable Despair: child experiences hopelessness and becomes quiet, withdrawn, and apathetic Detachment: child becomes interested in the environment, plays and seems to form relationships with caregivers and other children. If parents reappear, the child may ignore them.
What are some common children’s responses to illness and hospitalization and related nursing care. Infants experience some separation anxiety, but separation anxiety remains the major stressor for the toddler. The older the child, the more elaborate the protest. The child not only cries by also may cling to the parent, kick, and generally create a scene. Parents need to understand that this behavior is a sign of healthy parent-child attachment. The toddler may resist bedtime and eating, temper tantrums, regression (esp. with toileting and eating). Nurses must encourage parents to reinforce appropriate behavior while allowing the regressive behavior to occur. According to Erikson, the major task of the toddler period is developing autonomy. Control is a major issue with this age-group. Toddlers especially need sameness (rituals, routines) Mention Leah here and the laying out of the dolls, covers, etc. at bedtime. Hospitalization which has its own set of rituals, can disrupt the world of the toddler.
What are some common children’s responses to illness and hospitalization and related nursing care. Fear of injury and pain: **the preschooler fears mutilation. The child who has surgery experiences increased fear. Also afraid of intrusive procedures, and because of their literal interpretation of words, they often imagine treatments to be much worse than they are. Imagination can go wild during illness. Preschooler may believe that the illness occurred because of some personal deed or thought or perhaps just because the child touched something or someone. This age child has attained a good deal of independence in self-care and they expect to maintain their independence in the hospital. Like the toddler, a preschooler likes familiar routines and rituals and may show some regression if not allowed to maintain some areas of control. Set limits: “would you like to read a book before I come in to give you the dressing change?” You are allowing the child to know you will be back, yet you are negotiating with him to give a sense of some control. Preschoolers may believe that their illness is somehow r/t to a thought or deed. This can lead to feelings of guilt, shame, and increased stress at a time when the child has to cope with several other stressors. The nurse’s role is to assess the child for this type of thinking, and assist the child in identifying unfounded fears and beliefs. The use of puppets, dolls, and drawings can help children deal with their feelings.
What are some common children’s responses to illness and hospitalization and related nursing care. Older children may be more concerned with missing school and the fear that their friends will forget them . The need to adjust to an unfamiliar environment and the regression seen in ill children, however, increase the likelihood that some separation anxiety will take place. Injury and pain: concerned with body disability and death. More relaxed about having a physical exam or having the eyes or an ear examined but is uncomfortable with any type of genital examination. Wants to know the reason for the procedures and they ask relevant questions about their illness. They can relate actions to becoming ill. (not wearing a coat or eating nutritiously may cause illness. Loss of control: School age children are movers and shakers.. They control their self-care and typically are highly social. They like being involved, and most fill their days with activites. Illness can changes all these patterns. Friends are very imp to this age group. The nurse can encourage children of this age to be involved in their own care.
What are some common children’s responses to illness and hospitalization and related nursing care. Adolescents unsure if they want their family with them or not. Some enjoy the freedom. Ideally, the peer group will support the ill friend. (Westlake football player recently in the news…..surrounded by his friends was stated in the newspaper) Fear of injury and pain: appearance to this age is crucial. Therefore illness or injury that changes their perception of themselves can have a major impact. The adolexcent who has diabetes may not want to eat different foods or take time out from an activity for injections. They do not want to call attention to themselves. They also give the impression that they are not afraid, even though they are terrified. (story about overdose kids who were teens and pointing out to them the result of their overdose, even though they say it wasn’t for real) Loss of control: control very imp. to this age. Understanding this issue is key when caring for adolescents. Giving the adolescent some control avoids endless power struggles. Control issues can cause a major conflict between adolescents and parents. Parents often feel like ping-pong balls as they are bounced back and forth by a child who wants help one and rejects it the next.
4. What specific age group is most impacted by separation? Infants experience some separation anxiety, but separation anxiety remains the major stressor for the toddler.
How does each of the following affect a child’s response to hospitalization? a. Age and cognitive development b. Parents response to hospitalization c. Preparation of child and family d. Coping skills A child or adolescent bases their understanding of hospitalization on what two main factors?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
6. What are age-appropriate nursing interventions and approaches to caring for the hospitalized child?
7. Describe the advantages of Therapeutic Play in meeting the childs psychosocial and developmental needs during hospitalization including: a. specific play techniques related to each developmental age groups. Therapeutic play differs from normal play in its design and intent; it is guided by the healthcare team and is intended to meet the needs of the child. Child life specialists are available in hospitals and share their expertise in child growth and development as it r/t play. Emotional outlet play is called “dramatic play” In this type of play the child acts out the real-life stressors. This could include abuse, neglect or pain. Children might use this type of play with hammers, pegs, boxing gloves, anatomical dolls, drawing (colors selected are highly suggestive of feelings) Teaching can be used in preoperative teaching and teaching before a new, painful, or extensive procedure. Hospital equipment may be used for this type of teaching, ie., taking the blood pressure on a teddy bear. Developing a plan that will stimulate and engage the child in the activity is a challenge. The nurse should include age-appropriate growth and development activities when planning care. Allowing the child to participate, or being rewarded can enhance coooperation (like you getting them to drink a fell glass of water before having an IVP); then awarding them with stickers, baseball cards, etc. for their positive actions
What are some of the approaches the nurse can use in assisting children and parents during admission to the hospital?
7. What are some of the approaches the nurse can use in assisting the children and parents to prepare for hospitalization?
9. What are ways the nurse can assist the parents in adjusting to their child’s hospitalization?
13. During assessment of pain in children, what clinical manifestations would be exhibited in each of the following age groups? Infant- Toddler- Preschool- Adolescent-
14. What tools are utilized in assessing pain according to the child’s age and developmental abilities? Preschooler is able to localize pain and describe the pain.
15. What are some of the non-pharmacologic interventions / and nursing care to assist the child in pain?
15. What are some of the non-pharmacologic interventions / and nursing care to assist the child in pain? Behavioral distraction : Techniques such as distraction, relaxation, and imagery direct the person’s attention away from the pain sensation. Therefore, fewer signals associasted with pain can be transmitted to higher structures in the brain Assorted visuals : any object that visually distracts and allows stimulation of the mind. Light up toys, books, magic wands, bubbles, video games, movies Breathing techniques : modeling rhythmic breathing patterns, singing, blowing candles, deep breathing (for the older child) Comfort measures: a variety of sensory techniques that aim to soothe or provide alternate sensation to a pain ful stimulus…positions, ice, heat, etc. Diversional talk: words to change the focus of attention, to encourage the child and provide a little more courage to get throug a painful episode…”we’re almost through”, “You’re doing a great job, keep it up”
16. What are some of the pharmacologic interventions / and nursing care to assist the child in pain?