Stressors and reactions of children to hospitalization

1. Care of Hospitalized Child
Dr.Smriti Arora
Professor, Amity College of Nursing
Gurgaon
smritiamit@msn.com

2. Introduction
 Children are not small adults.
– Anatomical , physiological- BSA, HR, soft bones,
nerves, fontaneles
– Immunological
– Psychosocial- communicate, dependent on parent
– Cognitive – egocentric, magical thinking
 They require specialized pediatric care from
practiced professionals

4. Introduction
 The children’s reaction to illness,
perception to illness, body images are
of different at different age group.
 Therefore they need special attention
during each stage to help them for
appropriate growth and development.

5. Quality care to hospitalized child
 Structure
 Process
Child Friendly

6. Measures to make hospital environment
friendly for children:
 Provide good illumination
 Keep floors clear of fluid or objects that might
contribute to floors
 Use nonskid surfaces in washrooms
 Familiar with the area-specific fire plan
 Secure all windows, blinds and curtain cords.
 Keep plants away as they harbor gram negative
bacteria and molds that may affect
immunocompromised children.

8. Measures to make hospital
environment friendly for children:
 Electrical equipment should be in good working
order. It should be used only by personnel familiar
with its use and kept away from children.
 Furniture should be checked for safety. Infants,
young children, and those who are weak, paralyzed,
agitated, confused, sedated or cognitively impaired
should never be left unattended on treatment tables,
weighing scales or in treatment areas.
 Prevent fall from the beds, and cribs by raising the
side rails.

10. Measures to make hospital
environment friendly for children:
 Asses the safety of toys. Toys should be appropriate
to the child’s age, condition, and treatment.
 Setting limits is essential, and children should know
where they are permitted to go and what they are
supposed to do.
 Ensure safe transportation for children within or
outside the unit.

11. A child friendly environment
should have:
 facilities, equipment and medications tailored
to fit the needs of children.
 bright colors, themed décor and plenty of
areas and opportunities to play

12. Impact of hospitalization on child
Hospital
Parent
Child

13. Impact of hospitalization on
child
 Child:
– Child’s developmental age
– Coping mechanisms
 Parents
– Presence of the mother, preparation of the mother, support
of the child by the mother
– parental values
– and socioeconomic status

14. Impact of hospitalization on
child
 Hospital
– The hospital environment is generally
considered to be threatening to school-age
children.
– length of hospitalization, nature and degree
of illness, type of procedure, and method of
preparation for the hospital experience.

15.  Children with chronic illness have identified
stressors related to
– the anticipation of surgical procedures, lengthy
and involved medical treatments,
– inadequate information about procedures,
– and disruption of daily routines
(Coyne, 2006; Hildenbrand, Clawson, Alderfer,
& Marsac, 2011; Kazak et al., 2005)

16. Stressors of hospitalization
Separation
anxiety
Loss of
control
Bodily
injury and
pain

17. Separation anxiety- infants and
toddlers
Phase of
protest
Phase of
despair
Phase of
detachment

18. Separation anxiety
1. Phase of protest
 Children react aggressively to separation.
 Refuse attention of anyone
 cry and scream for their parents, inconsolable.
 Continuously search for their parents, cling to parent
when they reach, and avoid or reject contact with
anyone else.
 Toddlers verbally and physically attack strangers,
attempt to escape from the area to find parents.
 These manifestations may last from hours to days
and ceasing only with physical exhaustion.

19. Separation anxiety
2. Phase of despair
 During this phase crying stops and depression is
evident.
 Child is less active and shows no interest in food or
play.
 He looks sad, lonely, isolated and apathetic.
 Child may regress to earlier behavior like thumb
sucking, bed wetting, or use of a pacifier.
 Child’s physical condition may further deteriorate
from refusal to eat, drink or move.
 Others usually misinterpret this phase for child’s
cooperation, and adjustment to his hospitalization.

20. Separation anxiety
3. Phase of detachment
 Child appears to have finally adjusted to
the loss.
 Starts showing more interest in the
surroundings, plays with others and
seems to form new relationships.

21. Loss of control
 Children perceive a great amount of control
according to their age group. New situations like
hospitalization decrease the amount of control a child
feels.
 This feeling of loss of control causes a threat and can
affect childrens’ coping skills.
 So the nurses must have an insight into the type of
environment conducive to child’s optimum growth.
 The major areas of loss of control - physical
restriction, altered routine, and dependency; varies
according to different age groups.

22. Loss of control
Infants
 Infants attempt to control their environment through
emotional expressions, such as crying or smiling.
 According to Erikson, infants develop a ‘trust’ while
overcoming a sense of ‘mistrust’.
 Infants trust that their feeding, comfort, stimulation,
and caring needs will be met. So the care that the
infant receives matters. The trust acquired in infancy
provides the foundation for all succeeding phases.
 Inconsistent care and making changes in the infant’s
daily routine may lead to mistrust and loss of control.

23. Loss of control
Toddlers
 Erikson- the developmental task of toddlerhood is
acquiring a sense of autonomy while overcoming a sense
of doubt and shame.
 Their behaviors range from motor skills, play,
interpersonal relationships, ADL and communication.
When their pleasures are not met and they perceive
hospital routine and caregivers as obstacles, they react
with negativism and temper tantrums.
 Toddlers rely on the consistency and familiarity of daily
rituals to provide a measure of stability and control in their
life.
 Their rituals include eating, sleeping, bathing, toileting,
and play.

24. Loss of control
Toddlers
 When this daily routine is disrupted by hospitalization
their principle reaction is ‘regression’.
 Rigid schedules, altered caregiving activities,
unfamiliar surroundings, separation from parents, and
medical procedures decrease the toddler’s control
over their world.
 Prolonged loss of autonomy may result in passive
withdrawal from interpersonal relationships and
regression in all areas of development.

25. Loss of control
Preschoolers
 Preschoolers experience loss of control when
they are physically restrained, routines are
altered, and when they feel enforced
dependency.
 They take their hospitalization as a
punishment for their wrongdoings.

26. Loss of control
School-age children
 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 activities.
 Illness can change all these patterns. Friends
are very important to this age group.

27. Loss of control
Adolescents
 Control is very important to this age group. Understanding this
issue is key when caring for adolescents.
 Adolescents are unsure if they want their family with them or
not.
 Some enjoy the freedom. Ideally, the peer group will support
the ill friend. They want to hear from their friends frequently.
 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.

28. Bodily injury and pain
 When a child enters into a hospital he is most
concerned about pain and bodily injury.
 When children experience pain they become
reluctant to enter the hospital.
 Children in different age groups react
differently to pain.

29. Bodily injury and pain
Infants
 Infants may express pain by assuming certain
positions, such as squirming, writhing, jerking.
 Some infants may cry loudly after the procedure,
where as others are easily calmed by a gentle hug.
 Research has found that infants have stored
memories acute pain, experiences and react in
subsequent painful events with heightened
behavioral responses to pain.
 Older infants react intensely with physical resistance
and uncooperativeness.

30. Bodily injury and pain
Toddlers
 The older the child, the more elaborate/intense is the
protest. The child cries, 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).
 By the end of the toddler period a child is able to
locate their pain but not able to describe the intensity
of pain.

31. Bodily injury and pain
Preschoolers
 Have fear of injury and pain. They react with verbally
abusing their attackers. Here nurses need to
understand that this is just an expected normal
behavior from a preschooler. Sometimes they may try
to avoid the event by stating some excuses.eg –“ I
have to go to bathroom”.
 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.

32. Bodily injury and pain
Preschoolers
 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.
 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 can lead to feelings of guilt, shame and increased stress at
a time when the child has to cope with several other stressors.

33. Bodily injury and pain
School-age children
 Able to describe their pain with words. Most of the time they
demand explanation of procedures from the caregivers.
 Be aware of nonverbal clues- a serious facial expression, a half
hearted reply of “ I am fine ”, silence, lack of activity, or social
isolation, as signs of the need for help.
 Older children may be more concerned with missing school and
the fear that their friends will forget them.
 School aged children are more relaxed about having a physical
examination or having the eyes or an ear examined but are
uncomfortable with any type of genital examination.
 They want to know the reason for the procedures and ask
relevant questions about their illness. They can relate actions to
becoming ill like not wearing a coat or eating nutritiously may
cause illness.

34. Bodily injury and pain
Adolescents
 Body image is paramount during adolescence.
Because of the development of secondary sexual
characteristics, adolescents are concerned about
privacy.
 They may react to pain with much self control but
they will not tolerate lack of privacy during
procedures.
 They tend to observe all the procedures you
demonstrate on them.

35. Bodily injury and pain
Adolescents
 One has to look for the physical indications, such as
limited movement, excessive quiet or irritability, as
adolescents may not disclose their level of pain to
others : appearance to this age is crucial.
 Therefore illness or injury that changes their
perception of themselves can have a major impact.

36. Nursing Care Of A
Hospitalized Child

37. Infant (trust versus 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.
 Assign same nurse.

38. Infant (trust versus mistrust)
 Allow parents to be present during
procedures and comfort afterwards.
 Keep frightening objects away from view.
Provide swaddling, soft talking to soothe.
 Play close attention to light and sound
stimulation

39. Toddler (autonomy versus
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 the stage child is in.
 Bring infants security object -- favorite toy, blanket.
 Set limits, give choices on simple decisions.

40. Toddler (autonomy versus
shame and doubt)
 Teach parents that child may regress, may
promote potty chair if child is trained.
 Promote ritualistic behavior for bedtime.
 Teach parents about hazards (crib, chair,
toys, equipment). Be sure to supervise when
out of crib.

41. Preschooler ( initiative versus
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.
 Assess his likes and dislikes among food items. Give
small portions.
 Make environment comfortable and accept messes.
 Encourage intake of fluids with games.

42. Preschooler ( initiative versus
guilt )
 Provide consistent environment.
 Reinforce coping behavior.
 Provide with as much mobility as possible.
 Provide play and diversional activities.
 Avoid intrusive procedures as much as
possible.
 Assess child’s perception by asking to draw a
picture and tell about it.

43. School age ( industry versus
inferiority)
 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.

44. School age ( industry versus
inferiority)
 Include in decision-making (time to do it,
preferred site).
 Encourage active participation (removing
dressings).
 Plan child’s day if possible with child’s input.
 Maintain clear and consistent limits.
 Allow for privacy.

45. Adolescent ( identity versus identity
diffusion/role confusion )
 Assess knowledge.
 Encourage questioning regarding fears, or risks.
 Involve in decision-making.
 Ask if child 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 perform normal grooming.
 Allow favorite food to be brought in if not on a special diet.

46. Care of hospitalized child includes:
 Prepare for hospitalization
 Prevent or minimize separation
 Minimize loss of control
 Prevent minimize bodily injury
 Allow for regression
 Provide pain management ( Atraumatic care)

47. Care of hospitalized child
includes:
 Provide for developmentally appropriate
play activities
 Maximize potential benefit of
hospitalization

48. Play therapy – to reduce stress &
anxiety
 Great for socialisation, motor skills, and intellectual
development. In hospital, playing with children can
also create understanding and serve as a distraction,
as well as help in:
 Building rapport and providing a positive experience
 Encouraging development and independence
 Relieving stress and boredom
 Helping to prepare for procedures
 Normalising the environment
 Breeding familiarity with hospital equipment
 Providing opportunities to talk and listen

49.  Research suggests that children facing surgery feel
upset, angry and depressed when they are not
provided with sufficient information (Coyne, 2006).
 They have also expressed feelings of anxiety and
worry related to the treatment process (Carney et al.,
2003).

50. Preoperative management
 Elicit history, review previous medical records, interview
the parent and child.
 Perform focused preoperative assessment, do physical
examination.
 Psychological preparation: pre-admission educational
programmes reduce the stress of admission for parents
and children. Educate the caregiver about the surgery,
encourage questioning.
 Give age appropriate explanation to the child about
surgery.
 Toys and a relaxed atmosphere are essential.
 Avoid separating the child from the parent.

51. Preoperative management
 Drape child in gown, cap and mask.
 Ensure anaesthetic check up is done.
 Premedication: anxiolytics like midazolam for
the particularly anxious child, anticholinergics
and antibiotics. Topical local anaesthetic
creams - Emla for painless cannulation.
 Apply identification band.
 Inform parents where to wait and where will
the child be shifted after surgery.

52. Preoperative management
 Recognize the need for blood transfusion.
 Fasting guidelines: clear written instructions
about the period of preoperative fasting
should be issued and the importance of
compliance stressed (prevents aspiration).
 Ensure that all the investigations are done
and reports attached in the file.
 Ensure consent is obtained from caregivers
for surgery.

53. Postoperative management
 Ensure airway is patent. Perform oral, ET or TT suctioning
as required.
 Change position 2 hourly.
 Administer oxygen. Monitor ABG values.
 Maintain fluid and electrolyte balance, administer IV fluids
at correct drop rate, maintain intake output chart. Monitor
serum electrolyte values. Notify physician if abnormal.
 Follow standard precautions while performing any
procedure to avoid infections
 Monitor and record vitals.
 Keep the child NPO until advised which depends on the
type of surgery done. Usually oral feeds are started once
the peristalsis returns.

54. Postoperative management
 Assess and minimize pain by
administering analgesics. Incorporate
play while dealing with child.

55. Postoperative management
 Monitor for complications like nausea, vomiting,
bleeding, delayed micturition, unsteady gait etc.
 Give postoperative health education to the caregivers
related to the surgery e.g. breathing exercises,
advice about ambulation, colostomy care etc.
 Advise for follow up at regular intervals.

56. Making a hospital stay happier
 Being honest, open communication, trusting
relationship
 Promote the positives. Praise the child for their
efforts and encourage their progress, verbally and
with rewards.
 Reward them with a favourite toy or book.
 Anxiety- Practice some relaxation techniques, like
focusing on breathing to calm down or releasing
stress by squeezing a ball. Distract child by talking
through what is happening, or divert their attention
with a conversation, favourite story or activity

57. Summary
 Stressors – separation anxiety, loss of
control , body injury
 Child friendly environment