The Hospitalized Child

Meaning of Illness to Children

Factors affecting response to illness Cognitive ability Past experiences Level of knowledge Think cause of illness is magical Culture Spirituality Age appropriate interventions/langu age

Communication
Allow children time to feel comfortable Avoid sudden or rapid movements, extended eye contact, or gestures that may be seen as threatening Talk to the parent if the child is initially shy
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Stressors of Hospitalization & Childrens Reaction

Major stresses of hospitalization: Separation from parents and loved ones Fear of the unknown Loss of control & autonomy Bodily injury

Separation Anxiety: Anaclitic Depression

Major stress from middle infancy throughout preschool years Most expected in hospitalized child AGES: 16-30 months
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Manifestations of Separation Anxiety

Protest phase (observed later infancy) Cry and scream, clings to parent Despair phase Crying stops; evidence of depression Detachment phase Denial; appears to have finally adjusted to loss (superficial adjustment) May seriously affect attachment to parent after separation Slide 6

Protest& Despair Phase of Separation Anxiety

Protest Despair

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Loss of Control: Infants & Toddler Needs

Infants Trust Consistent loving caregivers Daily routines Toddlers Autonomy Daily routines and rituals Loss of control may contribute to:

Regression of behavior Negativity Temper tantrums

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Loss of Control: Preschool/School-age

Preschooler

Egocentric and magical thinking typical of age May view illness or hospitalization as punishment for misdeeds

School-age Striving for independence and productivity Fears of death, abandonment, permanentinjury Boredom

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Loss of Control: Adolescents

Struggle for independence and liberation Separation from peer group May respond with anger, frustration Need for information about their condition
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Fears of Bodily Injury and Pain

Common fears among children May persist into adulthood and result in avoidance of needed care

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Pain Assessment: Infants

Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness Examples: FLACC scale, NIPS scale

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Young Infants Response to Pain

Generalized response of rigidity, thrashing Loud crying Facial expressions of pain/discomfort (grimace) No understanding of relationship between stimuli and subsequent pain
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Pain Assessment: Toddlers

Toddlers may have a word that is used for pain (owie, booboo, ouch or no it hurts); Be sure to use term that toddler is familiar with when assessing.

Can also use FLACC scale, or Oucher scale (for older toddlers)
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Pain Assessment: Preschoolers

Think pain will magically go away May deny pain to avoid medicine/injections FEAR INJECTIONS FACES scale, poker chips and Oucher scale may be used
Photo Source: Del Mar Image Library; Used with permission

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School-Age Childs Response to Pain

Stalling behavior (wait a minute) Muscle rigidity May use all behaviors of young child
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Pain Assessment: Older Children

Older children can describe pain with location and intensity

FACES scale, poker chips, visual analog scales, and numeric rating scales
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Adolescent
Less vocal protest, less motor activity Increased muscle tension and body control More verbalizations (It hurts, Youre hurting me)

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Pain Scales
Poker Chip Oucher Scale Color Scale

Visual AnalogScale
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Family Reaction to Hospitalization

Parents reaction Disbelief Anger/& guilt Fear, anxiety, frustration Sibling reactions Loneliness, fear & worry Anger, resentment, jealous, guilt
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Normalizing the Hospital Environment

Promote freedom of achievement Maintain childs routine, if possible Time structuring: daily schedule Self-care (age appropriate) Schoolwork Friends and visitors
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Altered Family Roles

Anger, resentment and jealousy between siblings and ill child Ill child obligated to play sick role Parents continue pattern of overprotection and indulgent attention Rivalry: greatest with sibling who is nearest ill childs age

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Nursing Care of the Child Who is Hospitalized

Interventions should focus: Eliminating or minimizing the stressors of separation, loss of control and bodily injury and pain for children Providing specific supportive strategies for family members.
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Preventing or Minimizing Separation

Primary nursing goal
Prevent separation, especially for children younger than 5 years

Family-centered care
Family: partners in care of child

Parents are not visitors Familiar items from home

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PREPARATION FOR HOSPITALIZATION

Group size and timing of preparation Setting of the tour Preparatory materials Opportunity for discussion Prehospital counseling by parents

Preparing Child for Hospitalization

Parents: seek guidance from nurse on what/how much to tell child B/w 2 & 7: Tell the child about a scheduled ambulatory procedure/and or hospitalization as many days before procedure as the childs age in years i.e. 2 yr old: inform 2 days before hospitalization Older than 7: inform as soon as parents are aware

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Family Preparation
Plan for hospitalization Urge parents to ask questions about hospitalization Advise parents to ask about the plan of care

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Infant Preparation
Pack their favorite toy, blanket or

pacifier

Primary care-giver should be present participating in plan of care Consistent nurse assigned for continuity of care Approach in a nonthreatening manner
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Preparing Toddler or Preschooler

3 chief fears:
1._____________________ 2._____________________ 3._____________________

Bring favorite toy or personal item:______ (____________) Dont throw anything away without first asking child or parent

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Toddler/Preschooler
Provide a personal item from parent in case of emergency admission Read books about hospitalization with children

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Preschooler
Role playing: effective means of preparation for preschooler: acting out a hospitalization with puppets or dolls Fear of physical harm/mutilation: BAND-AIDS Explanations must be simple terms, brief, honest, and natural terms Believe illness is form of punishment Use demonstration play when providing health teaching Medical or therapeutic play-allows child to act out his or her experiences

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School-Age/Adolescent
School-age
Books about surgery and hospitalization are helpful: School-age child Factual information of what will happen during hospitalization: both age groups Describe scars Caution when explaining that anesthesia causes a special sleep not that a child is put to sleep Hospitalization > 1 week: child will need schooling.

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School-Age/Adolescent
Adolescent: Respect need for privacy esp. with adolescent Welcome peer visitor Focus on appearance
Concerned with _________________

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What if..
Becky's mother brought pots and pans to the hospital as Becky's favorite play items? Would you suggest she bring an actual toy?

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Preparing Child from Different Culture

Most important aspect: customs will seem different to child & family RN: prepare to act as liaison Language barrier: provide an interpreter Provide opportunity for parents to voice their fears & ask questions

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Preparing a Physically Challenged or Chronically Ill Child

Help child maintain contact with families, school friends. Encourage telephone calls, visits, emails, & letters

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Admitting an Ill Child & Family

Admit family as a single entity First impressions are lasting ones During introduction, stoop down so that you are face to face with child Call child by name or ask for a nickname Make sure child has armband

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Assessment on Admission
Assess childs level of preparation Interview parents for a nursing hx Make note of any medication or allergy hx on childs plan of care Record vital signs, ht/wt. Obtain specimens for u/a Explain all equipment; allow child to touch and handle as much as possible
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Assessment on Admission..
Inspect for gross motor ability Listen for language ability Perform PE Assess coping ability

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Parental & Child Anxiety

Orient family to hospital stay prior to admission Give them basic info Emergency: take time to explain what was happening while child was being taken care off Ask parents if they have any questions If parents have to leave, make sure they see the child before they go Let children wear their own clothes if possible

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Hospital Stay..
Toddler & Preschooler Express feelings better, louder and longer Feelings of separation are extremely intense because they do not understand time School-age & Adolescent React better to separation anxiety Normal to feel anxious when away from parents

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Providing Continuity of Care

One nurse gives care to maintain continuity as possible. Helps minimize effect of separation from parents
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Providing Developmentally Appropriate Activities

Using play/expressive activities to minimize stress
Diversional activities Toys: safe; age-appropriate Expressive activities: play Play therapy Therapeutic play Dramatic play Creative expressions

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Promoting Play for Ill Child

Provides diversion & relaxation Helps child feel more secure in a strange environment Lessens stress of separation & feeling of homesickness Provides means for release of tension Provides and expressive outlet

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Types of Play
Observational (______) Parallel play (________) Associative (_________) Cooperative (_________)
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Play in the Hospital

Infants: mobiles, blocks, soft toys,
Toddler: put in and take out toys Preschooler: creative materials School-age: shuffleboard, tossing

rattles

sand bags, board games, card games, video games, stamp collecting Adolescent: table tennis, pool tables, conversation with peers

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Therapeutic Play
Play technique that can be used by nurses to better understand childrens feelings and thoughts. Helps children deal with concerns and fears

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Play Therapy
Psychoanalytic technique used by psychiatrists to help children understand their feelings and thoughts and motivations better Energy Release
Helps release energy by pounding, hitting, running, punching or shouting.

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Creative Play

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Dramatic play
Used for emotional release, allowing children to reenact frightening or puzzling hospital experiences. Use of puppets, replicas or actual hospital equipment Puppets: very effective for communicating; children view them as peers
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Checkpoint
Suppose Becky shows signs of separation anxiety. The first stage of separation anxiety is marked by: a. Loud, demanding crying. b. Silent, sullen protest. c. Quiet introspective thought. d. Inability to respond verbally.
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PROCEDURE MEDICATION
INFANT
Keep painful procedure to a minimum Allow parent to accompany Parent DO NOT RESTAIN CHILD

TODDLER/ PRESCHOOL
Short, simple explanation Close to time of procedure-worry Let handle equipment
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PROCEDURE MEDICATION
SCHOOL-AGE and ADOLESCENT Offer theory and reason & souvenirs of procedure Reassurance Privacy & modesty Participation in care
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