Hospitalized child


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  • 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is agitated, resists caregivers, cries, and is inconsolable Despair: child experiences hopelessness and becomes quiet, withdrawn, and apathetic Detachment: child becomes interested in the environment, plays and seems to form relationships with caregivers and other children.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?  
  • Hospitalized child

    1. 1. 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
    2. 2. 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
    3. 3. Infant Experiences some separation anxiety at about 6 months of age They can sense the anxiety their parents are experiencing
    4. 4. Stages of Separation Protest Despair DetachmentScreaming, crying, Child becomes Lack of protest wheninconsolable hopeless and becomes parents leave quiet, withdrawn,Clinging to parents apathetic Appearance of being happy and contentAgitated 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.
    5. 5. Toddlers **Separation anxiety Nurses experience protest and despair in this group Fear of injury and pain Regressive behavior
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. Toddlers
    10. 10. 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
    11. 11. 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
    12. 12. Nursing Care to Assist theChild with Hospitalization Related to Age
    13. 13. 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
    14. 14. 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.
    15. 15. 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
    16. 16. Pre Schooler This pre-schoolers parents are taking the time to prepare her for hospitalization by reading a bookrecommended by the nurse. Such material should be appropriate to the child’s age and culture. Why doyou think that having the parents read this material is valuable? See Box 35-2 p. 891
    17. 17. 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
    18. 18. School Age ChildAllowing 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.
    19. 19. 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 theprocedure 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?
    20. 20. School Age Child Some hospitals offer a special classroom and teacher for childrenundergoing a lengthy hospital stay, enabling them to remain current with their school work. The child who falls behind other studentsmight not fit in when he or she returns to school or might be required to repeat a grade.
    21. 21. 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
    22. 22. 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.
    23. 23. 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
    24. 24. 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
    25. 25. Pet Therapy Hospitals may have pet therapy from speciallytrained animals to provide comfort and distraction during healthcare.
    26. 26. 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
    27. 27. 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
    28. 28. 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
    29. 29. 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.
    30. 30. 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.
    31. 31. 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
    32. 32. Nursing Care to Assist Families to CopeIt is important to allow the parents to be a part of thechild’s care.Reunite the family as soon as possible after surgery. Thischild has just undergone surgery and is in the postanesthesia care unit (PACU). Although the child’sphysical care is immediate and important, remember thatboth the child and the family have strong psychosocialneeds that must be addressed concurrently. It isimportant to reunite the family as soon as possible aftersurgery.
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. Pain AssessmentNeonatal characteristic facial responses to pain include: bulged brow, eyessqueezed 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
    38. 38. 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.
    39. 39. 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.
    40. 40. 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
    41. 41. 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
    42. 42. Non-pharmacological Pain Management Behavioral distraction Assorted visuals Breathing techniques Comfort measure  Repositioning, holding  Touching, massaging  Warm or cold compresses Diversional talk Guided imagery Biofeedback Progressive muscle relaxation
    43. 43. Pharmacologic Interventions for Pain Analgesics  Patient-controlled analgesia  Topical anesthetic cream Nonsteroidal antiinflammatory drugs Opioids Conscious sedation Epidural analgesia
    44. 44. 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.
    45. 45. 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.