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PEDIATRIC HEALTH NURSING UNIT V : CARE OF CHILD & FAMILY DURING HOSPITALIZATION

MUHAMMAD SULIMANPost RN BSc.N

ROYAL COLLEGE OF NURSING SWAT

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ObjectivesAt the end of this session the students will be able to: Identify the stressors of illness and hospitalization for children during each developmental stage. List essential priorities of nursing care upon a child’s admission to the hospital. Review nursing interventions that prevent or minimize the stress of separation during hospitalization. Discuss nursing interventions that minimize the stress of loss of control during hospitalization. Describe nursing interventions that minimize the fear of bodily injury during hospitalization.

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Cont… Outline nursing interventions that support parents, siblings, and family during a child’s illness and hospitalization. Describe nursing interventions needed when children are admitted to special units such as the emergency department.

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IntroductionOften, illness and hospitalization are the first crises

children must face. Especially during the early years, children are particularly vulnerable to these stressors because (1) stress represents a change from the usual state of health and environmental routine and (2) children have a limited number of coping mechanisms to resolve stressors. Major stressors of hospitalization include separation, loss of control, bodily injury, and pain.

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Cont…Children’s reactions to these crises are influenced

by their developmental age; their previous experience with illness, separation, or hospitalization; their innate and acquired coping skills; the seriousness of the diagnosis; and the support system available. Children also expressed fears caused by the unfamiliar environment or lack of information; child–staff relations; and the physical, social, and symbolic environment (Samela, Salanterä, and Aronen, 2009).

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Experience of HospitalizationHospitals can be threatening, frightening and painful

environments where children are faced with strangers who want to ‘do’ things to them. Illness, trauma and hospital care are often the most traumatic things children experience, even with the presence of their parents.

Hospitals used to be places of long stays, routine, rigidity, restricted visiting, limited emotional care and often painful experiences for children. Much of this has changed; however, it does not necessarily alleviate how children experience what is happening to them.

What is trivial to an adult can be a major stressor to a child.

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SEPARATION ANXIETYThe major stress from middle infancy throughout the

preschool years, especially for children ages 6 to 30 months, is separation anxiety, also called anaclitic depression. During the stage of protest, children react aggressively to the separation from the parent. They cry and scream for their parents, refuse the attention of anyone else, and are inconsolable in their grief. In contrast, through the stage of despair, the crying stops, and depression is evident. The child is much less active, is uninterested in play or food, and withdraws from others.

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Cont…The third stage is detachment, also called denial.

Superficially, it appears that the child has finally adjusted to the loss. The child becomes more interested in the surroundings, plays with others, and seems to form new relationships. However, this behavior is the result of resignation and is not a sign of contentment. The child detaches from the parent in an effort to escape the emotional pain of desiring the parent’s presence and copes by forming shallow relationships with others, becoming increasingly self-centered, and attaching primary importance to material objects.

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Cont…This is the most serious stage in that reversal of the

potential adverse effects is less likely to occur after detachment is established. However, in most situations, the temporary separations imposed by hospitalization do not cause such prolonged parental absences that the child enters into detachment. In addition, considerable evidence suggests that even with stressors such as separation, children are remarkably adaptable, and permanent ill effects are rare.

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Cont…Although progression to the stage of detachment is

uncommon, the initial stages are frequently observed even with brief separations from either parent. Unless health team members understand the meaning of each stage of behavior, they may erroneously label the behaviors as positive or negative. For example, they may see the loud crying of the protest phase as “bad” behavior. Because the protests increase when a stranger approaches the child, they may interpret that reaction as meaning they should stay away.

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Cont…During the quiet, withdrawn phase of despair,

health team members may think that the child is finally “settling in” to the new surroundings, and they may see the detachment may respond to the child’s behavior by staying for only short periods, visiting less frequently, or deceiving the child when it is time to leave. The result is a destructive cycle of misunderstanding and unmet needs.

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In the protest phase of separation anxiety, children cry loudly and are inconsolable in their grief for the parent.

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During the despair phase of separation anxiety, children are sad, lonely, and uninterested in food and play.

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Young children may appear withdrawn and sad even in the presence of a parent.

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MANIFESTATIONS OF SEPARATION ANXIETY IN YOUNG CHILDREN

Stage of ProtestBehaviors observed during later infancy include:• Cries• Screams• Searches for parent with eyes• Clings to parent• Avoids and rejects contact with strangers

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Cont… Additional behaviors observed during toddlerhood include:• Verbally attacks strangers (e.g., “Go away”)• Physically attacks strangers (e.g., kicks, bites, hits,

pinches)• Attempts to escape to find parent• Attempts to physically force parent to stayBehaviors may last from hours to days.Protest, such as crying, may be continuous, ceasing only

with physical exhaustion.Approach of stranger may precipitate increased protest.

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Stage of Despair

Observed behaviors include:• Is inactive• Withdraws from others• Is depressed, sad• Lacks interest in environment• Is uncommunicative• Regresses to earlier behavior (e.g., thumb sucking,

bedwetting, use of pacifier, use of bottle)Behaviors may last for variable length of time.Child’s physical condition may deteriorate from refusal to

eat, drink, or move.

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Stage of Detachment

Observed behaviors include:• Shows increased interest in surroundings• Interacts with strangers or familiar caregivers• Forms new but superficial relationships• Appears happyDetachment usually occurs after prolonged

separation from parent; it is rarely seen in hospitalized children.

Behaviors represent a superficial adjustment to loss.

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Experience of parentsMuch research has identified the adverse experience of

hospitalization on children. However, there can be impacts on parents that in turn affects the child:

• Anxiety when separated from their child• Feelings of guilt• Conflict between parents if they are not able to stay with

their child• Emotional impact of the ill child on their ability to cope• Physical demands of maintaining life and being at the

hospital• Development of postnatal depression.

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Hospital environment• Not child friendly• Many hospitals designed for adults• Noise and alarms may be frightening• Presence of machinery• Staff not aware of children’s needs

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The staff• Having to interact with strangers• Staff who are more oriented toward adults• Not considering the specific needs of children

and families• Staff who do not understand the child’s

developmental needs for support, preparation and care.

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Circumstances• Emergency situations in which the survival

needs override those of the child• When the child has experienced trauma• Safety of the child when there is a concern

about abuse• The child requires interventions that he/she

does not want.

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Pain and discomfort

• Procedures can be frightening and painful• Not all staff recognize children’s experiences• Pain experiences can lead to long-term problems• Children frightened of needles and equipment

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Factors that mediate children’s experiences of hospitalization

Involvement of children in their care Age, development and understandingSupport from parents or carers Involvement of parents in careUse of play and distraction to support children

Previous experiences of health care

Correct management of pain and discomfort

Resilience of child (and parents)

Good transitional care Length and place of stayCare by specifically educated children’s nurses

Child friendly hospital environment

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Minimizing separation• Involve parents in care• Plan care with parents• Provide facilities for parents to stay• Bring comforters, photos, toys, music to

remind child of home• Support for parents with financial difficulties• Monitor attachment

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Child friendly hospital environments• Staff trained to care for children• Decoration, furniture and surroundings child

focused• Provision of play areas and school facilities• Place for parents to stay• Safe environment

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Considering the child during interventions

• Provide pre-hospital preparation programme• Age-appropriate explanation and consent• Involve the child in care, especially for young

people• Respect the child’s growing autonomy• Involve play therapists

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Avoiding pain and discomfort• Assess the child’s pain or potential for pain• Ensure pain relief or prophylactic support• Provide clear and age-appropriate

explanations• Use of specific assessment tool to measure

and monitor pain

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NURSING TIP In many hospitals, child life specialists—health care

professionals with extensive knowledge of child growth and development and of the special psychosocial needs of children who are hospitalized and their families—help prepare children for hospitalization, surgery, and procedures. Although the structure of a program may vary depending on the size of the pediatric facility, the patient population, and the availability of ancillary services, the two primary program objectives for child life are consistent: (1) to reduce the stress and anxiety related to the hospitalization or health care– related experiences and (2) to promote normal growth and development in the health care setting and at home (Thompson, 2009).

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POSTHOSPITAL BEHAVIORS IN CHILDREN

Young ChildrenThey show initial aloofness toward parents; this may

last from a few minutes (most common) to a few days.

This is frequently followed by dependency behaviors:

• Tendency to cling to parents• Demands for parents’ attention• Vigorous opposition to any separation (e.g., staying

at preschool or with a babysitter)

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Cont…Other negative behaviors include:• New fears (e.g., nightmares)• Resistance to going to bed, night waking• Withdrawal and shyness• Hyperactivity• Temper tantrums• Food peculiarities• Attachment to blanket or toy• Regression in newly learned skills (e.g., self-toileting)

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Cont…Older ChildrenNegative behaviors include:• Emotional coldness followed by intense,

demanding dependence on parents• Anger toward parents• Jealousy toward others (e.g., siblings)

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GUIDELINES FOR ADMISSIONPreadmissionAssign a room based on developmental age, seriousness of diagnosis,

communicability of illness, and projected length of stay. Prepare roommate(s) for the arrival of a new patient; when children

are too young to benefit from this consideration, prepare parents.Prepare room for child and family, with admission forms and

equipment nearby to eliminate need to leave child.AdmissionIntroduce primary nurse to child and family.Orient child and family to inpatient facilities, especially to assigned

room and unit; emphasize positive areas of pediatric unit.

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Cont…Room—Explain call light, bed controls, television, bathroom,

telephone, and so on.Unit—Direct to playroom, desk, dining area, or other areas.Introduce family to roommate and his or her parents.Apply identification band to child’s wrist, ankle, or both (if not

already done).Explain hospital regulations and schedules (e.g., visiting hours,

mealtimes, bedtime, limitations [give written information if available]).

Perform nursing admission history .Take vital signs, blood pressure, height, and weight.Obtain specimens as needed and order needed laboratory work.Support child and assist practitioner with physical examination

(for purposes of nursing assessment).

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For extended hospitalizations, children enjoy doing projects to occupy time.

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Eric’s Daily Schedule7:30 AM – Breakfast, - morning bath

3:00 PM – Tutor – Study time

9:00 – Medications,dressing change

4:00 – Physical therapy

11:00 – Physical therapy 5:30 – Dinner

12:00 PM – Lunch 9:00 – Medications, dressing change

9:15 – Bedtime

Time structuring is an effective strategy for normalizing the hospital environment and increasing the child’s sense of control.

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BILL OF RIGHTS FOR CHILDREN AND TEENSIn this hospital, you and your family have the right to:• Respect and personal dignity• Care that supports you and your family• Information you can understand• Quality health care• Emotional support• Care that respects your need to grow, play, and learn• Make choices and decisions

From Association for the Care of Children’s Health: A pediatric bill of rights, Bethesda, MD, 1991, Author.

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FUNCTIONS OF PLAY IN THE HOSPITALProvides diversion and brings about relaxationHelps the child feel more secure in a strange environmentLessens the stress of separation and the feeling of

homesicknessProvides a means for release of tension and expression of

feelingsEncourages interaction and development of positive attitudes

toward othersProvides an expressive outlet for creative ideas and interestsProvides a means for accomplishing therapeutic goalsPlaces child in active role and provides opportunity to make

choices and be in control

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Play materials for children in the hospital need to be appropriate for their age, interests, and limitations.

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Drawing and painting are excellent media for expression.

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Placing children of the same age group with similar

illnesses near each other on the unit is both

psychologically and medically supportive. (Courtesy E. Jacob,

Texas Children’s Hospital, Houston.)

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Parental presence during hospitalization provides emotional support for the child and increases the parent’s sense of empowerment in the caregiver role. (Courtesy E. Jacob, Texas Children’s Hospital, Houston.)

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The child who is going to have surgery may act out the procedure on a doll, thereby reducing some of her fear. (© B. Proud.)

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Before surgery, these children work with a child life specialist using a model of the body organs.

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The nurse is encouraging this child to deep breathe following surgery by using a pinwheel device.

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Pain ManagementPain is a concern of postoperative patients in any age

group. Most adult patients can verbally express the pain they feel, so they request relief. However, infants and young children cannot adequately express themselves and need help to tell where or how great the pain is. Longstanding beliefs that children do not have the same amount of pain that adults have or that they tolerate pain better than adults have contributed to under medicating infants and children in pain. Research has shown that infants and children do experience pain (Gallo, 2003).

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Cont..Pain is treated with pharmacologic & non

pharmacologic interventions (complementary & alternative therapies) to control pain & discomfort, as well as surgical procedures used to block pain impulse transmission.

Alternative & Complementary Therapies: Relaxation techniques, guided imagery, &

distraction (e.g., music, TV) – relaxes and distracts the client’s focus on pain; can increase circulation & lower BP.

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Cont.. TENS (External transcutaneous electrical nerve

stimulation) unit: Adjustable electronic stimulation via surface electrodes to prevent complete depolarization or block transmission of pain impulses.

Heat (muscle relaxation) or cold (local anesthesia) Patient controlled anesthesia (PCA) – allows client to

control the timing of the administration of the medication.

Acupuncture – stimulates nerves and blocks transmission of pain impulses.

Aromatherapy – induces relaxation response. Biofeedback – promotes muscle relaxation.

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Cont.. Massage – promotes deep relaxation, increases circulation to

affected par, increases energy flow Meditation and faith – relaxation & internal focus Reflexology – induces relaxation, increases circulation,

promotes energy flow, reduces anxiety Therapeutic touch – decreases anxiety, improves immune

response, alters pain perception Procedures:o Injection of local anesthetic into nerve (e.g. dental)o Cordotomy – severs anterolateral spinal cord nerve tractso Electrical stimulation – transcutaneos (skin surface), percutaneous

(peripheral nerve)o Peripheral nerve implant electrode to major sensory nerveo Dorsal column stimulator electrode to dorsal column

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Cont..Pharmacological interventions: Nonopiods – (Acetaminophen, aspirin, ketorolac, toradol,

ibuprofen, naproxen, celecoxib) Opiod analgesics – (Morphine sulphate, codeine,

hydromorphone, fentanyl, methadone, propoxyphene, hydrocodone)

Adjuvants – (corticosteriods, antidepressants, antiseizure, muscle relaxant, anesthetics, psychostimulants, sedatives, anxiolytics)

Narcotic antagonists – (nalmefene, naloxone hydrochloride, naltrexone)

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Distraction supplements pain control while a child is using PCA.

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Summary

➧ The cause of the illness, its treatment, guilt about the illness, past experiences of illness and hospitalization, disruption in family life, the threat to the child’s long-term health, cultural or religious influences, coping methods within the family, and financial impact of the hospitalization all may affect how the family responds to the child’s illness.

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Cont… ➧ The family caregivers’ role in preparing a child for hospitalization includes helping the child develop a positive attitude about hospitals, hospitalization, and illness and giving children simple, honest answers to their questions. ➧ Rooming-in facilities allow and encourage the caregiver to stay in the room with the child. This helps minimize the child’s concerns with separation from the caregiver, increases the child’s feelings of security, and helps to decrease the stress of hospitalization.

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Cont… ➧ The nurse can help ease the feelings of isolation in a child who is placed on transmission-based precautions by spending extra time in the room when performing treatments and procedures, reading a story, playing a game, or talking with the child. ➧ The three stages of response to separation seen in the child include protest, in which the child cries, refuses to be comforted, and constantly seeks the primary caregiver. When the caregiver does not appear, the child enters the second stage— despair—and becomes apathetic and listless. The third stage is denial, in which the child begins taking interest in the surroundings and appears to accept the situation.

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Cont… ➧ Preadmission education helps prepare the child for hospitalization and helps make the experience less threatening. During the preadmission visit the child may be given surgical masks, caps, shoe covers, coloring books, and even the opportunity to “operate” on a doll or other stuffed toy specifically designed for teaching purposes. ➧ After discharge the family should encourage positive behavior and avoid making the child the center of attention because of the illness.

Discipline should be firm, loving, and consistent.

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Cont.. ➧ Health professionals can help the adjustment of the child scheduled for surgery by determining how much the child knows and is capable of learning, helping correct any misunderstandings, explaining the preparation for surgery, and explaining how the child will feel after surgery. This preparation must be based on the child’s age, developmental level, previous experiences, and caregiver support.

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Cont… ➧ Pain in children may be indicated by behaviors such as rigidity, thrashing, facial expressions, loud crying or screaming, flexion of knees (indicating abdominal pain), restlessness, and irritability. Physiologic changes, such as increased pulse rate and blood pressure, sweating palms, dilated pupils, flushed or moist skin, and loss of appetite, also may indicate pain.

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Cont… ➧ Play is the principal way in which children learn, grow, develop, and act out feelings and problems. In hospital play programs, children may express frustrations, hostilities, and aggressions through play without the fear of being scolded. ➧ Infants, children, and their caregivers experience stress when a child is hospitalized, which may increase the frequency of accidents. Safety is an essential aspect of pediatric care. Children must be protected from hazards. Understanding the growth and development levels of each age group helps the nurse be alert to possible dangers for each child.

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The nurse uses charts with pictures to perform patient teaching before the child goes home.

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REFERENCES AND SELECTED READINGSBerger, K. S. (2006). The developing person through childhood and

adolescence (7th ed.). New York: Worth Publishers.Dlugosz, C. K., et al. (2006). Appropriate use of nonprescription

analgesics in pediatric patients. Journal ofPediatric Health Care, 20(5), 316–325.Dunn, D. (2005). Preventing perioperative complications in special

populations. Nursing 2005, 35(11), 36–45.Hockenberry, M. J., et al. (2006). Implementing evidence based nursing

practice in a pediatric hospital. Pediatric Nursing, 32(4), 371–377.Hockenberry, M. J., & Wilson, D. (2007). Wong’s nursing care of infants

and children (8th ed.). St. Louis, MO: Mosby Elsevier.Lafleur, K. J. (2004). Taking the fifth vital sign. RN, 67(7), 30–37.Little, K., & Cutcliffe, S. (2006). The safe use of children’s toys within

the healthcare setting. Nursing Times, 102(38), 34–37.