This document provides information on caring for hospitalized children. It discusses the stressors children face during hospitalization, including separation from parents, loss of control, and fear of injury. It outlines the developmental stages of separation anxiety and interventions to support children and their families. These include minimizing separation, creating a child-friendly environment, preparing children for procedures, providing age-appropriate explanations, assessing and treating pain, and using play and distraction. The document emphasizes the importance of involving parents, explaining hospital routines, and respecting the child's needs, autonomy, and bill of rights while hospitalized.

1. PEDIATRIC HEALTH NURSING
UNIT V : CARE OF CHILD & FAMILY DURING
HOSPITALIZATION
MUHAMMAD SULIMAN
Post RN BSc.N
ROYAL COLLEGE OF NURSING
SWAT
1

2. Objectives
At 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.
2

3. 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.
3

4. Introduction
Often, 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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5. 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).
5

6. Experience of Hospitalization
Hospitals 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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7. SEPARATION ANXIETY
The 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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8. 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.
8

9. 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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10. 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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11. 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.
11

12. In the protest phase of separation anxiety, children cry loudly and are
inconsolable in their grief for the parent.
12

13. During the despair phase of separation anxiety, children are sad, lonely,
and uninterested in food and play.
13

14. Young children may appear withdrawn and sad even in the presence of a
parent.
14

15. MANIFESTATIONS OF SEPARATION
ANXIETY IN YOUNG CHILDREN
Stage of Protest
Behaviors 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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16. 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 stay
Behaviors 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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17. 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.
17

18. Stage of Detachment
Observed behaviors include:
• Shows increased interest in surroundings
• Interacts with strangers or familiar caregivers
• Forms new but superficial relationships
• Appears happy
Detachment 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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19. Experience of parents
Much 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.
19

20. 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
20

21. 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.
21

22. 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.
22

23. 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
23

24. Factors that mediate children’s
experiences of hospitalization
Involvement of children in their care Age, development and understanding
Support from parents or carers Involvement of parents in care
Use 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 stay
Care by specifically educated children’s
nurses
Child friendly hospital environment
24

25. 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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26. 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
26

27. 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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28. 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
28

29. 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).
29

30. POSTHOSPITAL BEHAVIORS IN CHILDREN
Young Children
They 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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31. 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)
31

32. Cont…
Older Children
Negative behaviors include:
• Emotional coldness followed by intense,
demanding dependence on parents
• Anger toward parents
• Jealousy toward others (e.g., siblings)
32

33. GUIDELINES FOR ADMISSION
Preadmission
Assign 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.
Admission
Introduce 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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34. 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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35. For extended hospitalizations, children enjoy doing projects to
occupy time.
35

36. Eric’s Daily Schedule
7:30 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.
36

37. BILL OF RIGHTS FOR CHILDREN AND TEENS
In 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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38. FUNCTIONS OF PLAY IN THE HOSPITAL
Provides diversion and brings about relaxation
Helps the child feel more secure in a strange environment
Lessens the stress of separation and the feeling of
homesickness
Provides a means for release of tension and expression of
feelings
Encourages interaction and development of positive
attitudes toward others
Provides an expressive outlet for creative ideas and interests
Provides a means for accomplishing therapeutic goals
Places child in active role and provides opportunity to make
choices and be in control
38

39. Play materials for children in the hospital need to be appropriate for their
age, interests, and limitations.
39

40. Drawing and painting are excellent media for expression.
40

41. 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.)
41

42. 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.)
42

43. The child who is going to have surgery may act out the procedure on a doll,
thereby reducing some of her fear. (© B. Proud.)
43

44. Before surgery, these children work with a child life specialist using a model
of the body organs.
44

45. The nurse is encouraging this child to deep breathe following surgery by
using a pinwheel device.
45

46. Pain Management
Pain 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).
46

47. 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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48. 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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49. 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 tracts
o Electrical stimulation – transcutaneos (skin surface), percutaneous
(peripheral nerve)
o Peripheral nerve implant electrode to major sensory nerve
o Dorsal column stimulator electrode to dorsal column
49

50. 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)
50

51. Distraction supplements pain control while a child is using PCA.
51

52. 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.
52

53. 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.
53

54. 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.
54

55. 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.
55

56. 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.
56

57. 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.
57

58. 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.
58

59. The nurse uses charts with pictures to perform patient teaching before the
child goes home.
59

60. REFERENCES AND SELECTED READINGS
Berger, 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 of
Pediatric 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.
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